
Class RC_U^_ 

Book #o 5 

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COPYRIGHT DEPOSIT; 



HUMAN 



INFECTION CARRIERS 



THEIE SIGNIFICANCE, RECOGNITION 
AND MANAGEMENT 



BY 

CHARLES E. SIMON, B.A., M.D. 

PROFESSOR OF CLINICAL PATHOLOGY IN THE UNIVERSITY OF MARYLAND SCHOOL 

OF MEDICINE AND THE COLLEGE OF PHYSICIANS AND SURGEONS, 

BALTIMORE, MARYLAND 




LEA & FEBIGER 

PHILADELPHIA AND NEW YORK 
1919 






Copyright 

LEA & FEBIGER 

1919 



FEB 24 1919 



CI.A5L2420 



PREFACE 



The volume which is herewith presented to the medical 
public is the outcome of the renewed interest which the sub- 
ject of Infection Carriers has acquired since the outbreak 
of the great war, and the resulting necessity of guarding 
the health of our troops against epidemics. With this has 
come an evergrowing demand for men trained in the recog- 
nition of carriers by laboratory methods and for these, more 
particularly, the book has been written. 

The request from the Surgeon-General's Office that medi- 
cal students be thoroughly drilled in the epidemiological 
aspects of the infectious diseases, including the laboratory 
side of the question, has brought up the problem in what 
department this training should be given. At the University 
of Maryland Medical School and College of Physicians and 
Surgeons of Baltimore, the carrier question was taken up by 
the Department of Clinical Pathology, to which it would 
properly seem to belong. The extension of the usual clinical 
pathological work along these lines has been found most 
satisfactory from every standpoint. It has already proven 
of absorbing interest to the student, and will no doubt lead 
to corresponding work, as a matter of routine, in the clinical 
laboratories of our hospitals. In the past it has been a source 
of constant regret to the writer that the clinician and the 
laboratory worker in so many of our institutions are, for the 
good of the patient, not sufficiently in touch, and it is for this 



IV PREFACE 

reason also, no doubt, that practically no sanitary work of 
any kind is either demanded or conducted in the majority 
of the hospital laboratories. It does not speak well for our 
institutions at which infectious diseases are treated which are 
apt to result in the development of the carrier state, that 
previous to the discharge of the patient no examination is 
made to ascertain whether or not he is apt to prove a menace 
to others. Team work is here urgently called for between the 
clinician and the worker in the clinical laboratory on the one 
hand, and the hospital authorities and the health department 
officials on the other. The amount of good that would result 
from such cooperation has been clearly brought out even dur- 
ing the brief period of time that work of this order has been 
carried on in our military camps, especially when directed by 
such men as stand at the head of our government sanitary 
service. 

Much of the work and many of the methods which have 
been collected in this volume are of very recent date. In 
bringing together the data which seemed of interest and 
importance, the writer has attempted to be as thorough as 
possible, but even so, no doubt, many valuable papers may 
have been overlooked. If this be so, he asks forbearance on 
the part of his readers and promises to add what may yet be 
missing in a subsequent edition, if this should be called for. 

A general idea of the arrangement of the subject matter 
may be found from a brief perusal of the table of contents. 
It will be noted that the book deals with a discussion of the 
problem under consideration only in connection with those 
diseases of bacterial origin or which are due to the activity 
of a filtrable virus in the dissemination of which healthy 
human carriers are now known to play a role, viz., carriers 
who either have never passed through an attack of the cor- 
responding malady themselves, or, having done so, have 



PREFACE V 

clinically recovered. The maladies in question are cholera, 
diphtheria, typhoid and paratyphoid fever, dysentery, epi- 
demic meningitis, poliomyelitis, pneumococcus pneumonia, 
certain streptococcus infections (such as camp septicemia, 
bronchopneumonia, septic sore-throat, erysipelas and puer- 
peral fever), influenza, and possibly also the pneumonic form 
of plague. 

Under these headings the various phases of the carrier 
problem have been discussed, i. e., the occurrence of active 
and passive carriers, the duration of the carrier state, the 
numerical relation between patients and carriers, the habitat 
and the virulence of the organisms, the mode of infection, 
concrete examples illustrating the danger of the carrier to 
others, the recognition of the carrier with a detailed descrip- 
tion of the laboratory methods involved, and the manage- 
ment of the carrier from the standpoint of the public health 
officer. In conclusion, there have been appended the most 
important State laws, municipal ordinances, and federal 
interstate regulations dealing with the carrier problem which 
have been enacted up to January 1, 1918. 

While the book was primarily written for students of 
medicine, it is hoped that it may prove of some service also 
to the health officer as well as to the general practitioner, 
without whose active aid and cooperation any material pro- 
gress looking to the eradication of infectious diseases from 
our midst will be impossible. 

Chakles E. Simon. 

Baltimore, Md., 1919. 



CONTENTS 



Introduction 17 

Active and Passive Carriers 19 

Asiatic Cholera 21 

Active Carriers 23 

Passive Carriers 24 

Virulence of Organisms 25 

Relation of Cholera Carriers to Outbreaks of the Disease . 25 

Examples Illustrating the Activity of Carriers .... 26 

Mode of Infection 29 

Habitat of Organisms * 30 

Intermittent Elimination 30 

Recognition of Carriers 32 

Bacteriological Technic 33 

Release of Carriers 34 

El Tor Carriers 34 

Management of Cholera Carriers 36 

Quarantine 36 

Bibliography 36 

Diphtheria 38 

Active Carriers 38 

Passive Carriers 40 

Habitat of Organisms ' 43 

Virulence of Organisms 44 

Pseudodiphtheria Bacilli 44 

Mode of Infection 45 

Examples of Infection by Carriers • . 46 

Recognition of Diphtheria Carriers 49 

Bacteriological Technic 49 

Management of Diphtheria Carriers 52 

Quarantine 52 

Use of Masks 53 

Medical Treatment of Carriers ....... 53 

Surgical Treatment 56 

Bibliography 59 



vin CONTENTS 

Plague 61 

Bubonic Type 61 

Pneumonic Type 61 

Active Carriers 61 

Passive Carriers 62 

Mode of Infection . 63 

Recognition of Plague Carriers 64 

Animal Experiment 64 

Bacteriological Technic 64 

Management of Plague Carriers 65 

Quarantine 65 

Bibliography 66 

Typhoid Fever 67 

Active Carriers 68 

Passive Carriers 70 

Intermittent Elimination of Organisms 71 

Tendency of Women to Become Carriers 72 

Habitat, of Organisms 72 

Association of the Carrier State* with the Presence of Gall- 
stones 75 

Virulence of Organisms 77 

Numerical Relation between Carriers and Cases of Typhoid 

Fever 79 

Manner of Infection 81 

Examples Illustrating the Activity of Carriers .... 82 

Recognition of Typhoid Carriers 90 

Widal Reaction in Carriers 90 

Bacteriological Technic 91 

Drigalski-Conradi Method 91 

Endo Method . 95 

Krumwiede's Method 96 

Russell's Method 98 

Management of Typhoid Carriers 99 

Medical Treatment 99 

Surgical Treatment 100 

Quarantine and Control of Carriers 100 

Paratyphoid Fever 103 

Bibliography 104 

Epidemic Cerebrospinal Meningitis 106 

Active Carriers 107 

Passive Carriers ; 109 

Duration of the Carrier Stage 1 10 

Virulence of the Organisms Ill 



CONTENTS IX 

Epidemic Cerebrospinal Meningitis — 

Habitat of the Organisms 112 

Distribution in the Upper Respiratory Tract . . . 113 

Relative Insusceptibility to Meningitis 114 

Examples Illustrating the Activity of Carriers . . . . 117 

Recognition of Meningococcus Carriers 122 

Olitsky's Method 123 

Management and Control of the Meningococcus Carrier . 128 

Medicinal Treatment 128 

Quarantine 130 

Bibliography 132 

Bacillary Dysentery 134 

Active Carriers , . 134 

Passive Carriers 136 

Manner of Infection 137 

Recognition of Dysentery Carriers 137 

Bacteriological Technic 137 

Management of Dysentery Carriers 139 

Bibliography 140 

Acute Poliomyelitis 141 

Active Carriers 143 

Passive Carriers 144 

Frequency of the Carrier State and Relative Insusceptibility 

to the Disease 148 

Inactivating Power of the Nasal Secretion upon the Virus of 

Poliomyelitis 148 

Manner of Infection 150 

Maintenance of the Carrier State 150 

Demonstration of the Carrier State 151 

Management of the Carrier 151 

Quarantine 151 

Bibliography 152 

Pneumococcus Pneumonia 154 

Varieties of the Pneumococcus and Their Relation to Pneu- 
monia 154 

Active Carriers 156 

Passive Carriers 156 

Frequency of Passive Carriers 158 

Duration of the Carrier State 160 

Common Colds as Sources of Pneumonia 160 

Habitat of the Organisms 160 

Mode of Infection 162 

Examples Illustrating the Activity of Pneumococcus Carriers 163 



x CONTENTS 

Pneumococcus Pneumonia — 

Recognition of Pneumococcus Carriers 169 

Bacteriological Technic 169 

Isolation of the Organism 169 

Precipitin Test 171 

Agglutination Test 172 

Type Determination in Sputa 173 

Management of the Pneumococcus Carrier of Types I and II 176 

Quarantine 176 

Use of Face Masks 176 

Disinfection of Carriers 178 

Management of Carriers of Types III and IV .... 179 

Protective Inoculation against the Pneumococcus . . . 180 

Bibliography 183 

Streptococcus Infections 185 

Camp Septicemia and Bronchopneumonia 187 

Duration of the Carrier State 191 

Manner of Infection 191 

Habitat of the Organism 191 

Mode of Invasion 192 

Relation between Camp Septicemia and Ordinary Winter 

Infections Occurring in Civil Life 192 

Relation of Camp Septicemia to Septic Sore Throat . 193 
Role of the Streptococcus Carrier in the Dissemination of 

Puerperal Fever and Erysipelas 194 

Recognition of the Streptococcus Carrier . . . . . . 195 

Demonstration of the Streptococcus Hemolyticus in Carriers 196 

Management of the Streptococcus Carrier . . . . . . 198 

Quarantine 198 

Exclusion from the Food Supply 200 

Exclusion from the Surgical Wards and the Operating 

Room 200 

Protective Inoculation against the Streptococcus . . . .201 

Bibliography • 203 

Influenza (Pfeiffer Type) 204 

Duration of Carrier State 206 

Origin of Secondary Outbreaks 206 

Habitat of the Organism 206 

Mode of Infection 207 

Recognition of Influenza Carriers 207 

Management of the Influenza Carrier . 209 

Bibliography 210 



CONTENTS xi 

Appendix 212 

State Laws and Regulations Pertaining to Infection Carriers 212 
Municipal Ordinances, Rules and Regulations Pertaining to 

Infection Carriers 236 

Maritime Quarantine 240 

Quarantine Laws of the United States 241 

Interstate Quarantine Regulations 244 



HUMAN INFECTION CARBIEBS. 



INTRODUCTION. 

The term "carrier" is used to denote an individual who, 
while clinically not suffering from the corresponding infec- 
tion, nevertheless harbors pathogenic organisms in his body, 
through the elimination of which he is capable either directly 
or indirectly of infecting others. The discovery that infec- 
tious diseases may be disseminated in this manner is of com- 
paratively recent date, and was largely the outcome of the 
epidemiological study of the cholera epidemic which occurred 
in certain districts of Germany during the years 1892 to 1894, 
along lines suggested by Koch. It had, of course, been 
recognized long before that certain diseases follow the routes 
of human travel, and that human beings themselves are in 
some manner concerned in the transmission of the corre- 
sponding organisms. But it was assumed that the latter were 
carried in the individual's belongings, such as his clothing 
or bedding, and possibly even about the exterior of his own 
person, such as his hair, his beard, his fingers. Observation 
has also shown, however, that notwithstanding the most 
thorough disinfection of every article of baggage that could 
conceivably have been contaminated, as well as similar 
treatment of the travelers themselves who were about to 
leave an infected district, cases of the corresponding disease 
nevertheless appeared sooner or later beyond the original 
zone of infection. An investigation of the travelers' past 
history may have revealed that they themselves had suffered 
from the disease in question not long before, but they were, to 
all intents and purposes, perfectly well at the time of their 
2 



18 HUMAN INFECTION CARRIERS 

arrival. In other instances no history of an antecedent illness 
could be obtained, though the persons may have admitted 
that they had lived in houses where such illness existed. Still 
others may have given no history either of a preceding illness 
or of contact with persons who themselves had been exposed. 
As, however, no other points of contact frequently existed 
between the primary and the secondary focus of disease, ex- 
cepting in the persons of travelers, the question naturally sug- 
gested itself whether, after all, these could not have acted as 
carriers of the corresponding organisms even though they 
had recovered from the malady or had indeed never been 
stricken, and as there was no reason for assuming that they 
carried the organisms about the exterior of their persons, there 
remained the possibility that they might have harbored them 
in those localities which represent their normal habitat in 
patients who are actually suffering from the corresponding 
diseases. 

Actual investigation of this question during the cholera 
epidemic of 1892-1894 showed that this possibility indeed 
existed; that, on the one hand, persons who had passed 
through an attack of the malady, no matter how light, might 
harbor cholera vibrios in their intestinal tract for a variable 
length of time after recovery, and, on the other hand, that 
there were perfectly healthy individuals who had at no time 
shown any evidence of the disease, but in whose feces the 
organisms could nevertheless be demonstrated. At the time 
of their discovery these findings, of course, attracted an 
enormous amount of attention, for the reason that a per- 
fectly simple explanation was here at once afforded of many 
phases connected with the dissemination of certain epidemic 
diseases which theretofore had been wrapped in complete 
obscurity. 

Analogous studies were then undertaken in connection with 
other infectious diseases, and it was soon found that cholera 
was not the only malady during the convalescence from which 
the corresponding organisms could persist in the body of the 
individual, and that perfectly healthy persons could become 
the carriers of various forms of pathogenic organisms without 
ever having shown symptoms of the corresponding disease. 



INTRODUCTION 19 

It was thus ascertained that convalescents from diphtheria 
may harbor the offending organisms much longer than the 
duration of the clinical illness, and represent a very serious 
menace to the community not only in themselves, but also 
through the large number of healthy carriers to which they 
may give rise. The same was then demonstrated for typhoid 
fever, and with the recognition of the role of the typhoid 
carrier came the realization that in the dissemination of 
enteric fever the infected human being is the only essential 
factor, in the absence of which the disease cannot continue 
to exist. Then followed the discovery that in the dissemi- 
nation of meningococcus meningitis also the human carrier 
plays a most important role; that here also the organism 
tends to persist after clinical recovery, and that normal 
human beings may harbor the organism in the upper respira- 
tory tract and cause the infection of others without falling 
victims themselves to its pathogenic properties. Still more 
recently it has been shown that poliomyelitis and certain 
forms of streptococcus infection, as well as certain types of 
pneumococcus pneumonia, are disseminated in the same 
manner, and future investigations will no doubt show that 
still other infectious diseases are transmitted through the 
activity of carriers of the type that we are here considering. 
As I have already pointed out, there are carriers of 
two kinds. On the one hand there are individuals who 
have passed through an attack of the corresponding 
malady themselves, who continue to harbor and excrete 
the offending organisms after clinical recovery, the so- 
called Daueransscheider of the Germans; while on the 
other there are persons who have at no time suffered from 
the disease — but who have been in contact with patients, or 
with other carriers, and who like the former are capable of 
infecting others. Carriers of this latter type the Germans 
have termed Bazillentrager. Practically speaking, it does not 
appear essential to distinguish between the two, but if for 
any reason this seems desirable we may appropriately term 
the first group active carriers, meaning thereby that in them 
the organisms have at one time or another exercised their 
specific pathogenic activity, while the latter group may 



20 HUMAN INFECTION CARRIERS 

correspondingly be termed passive carriers, to denote that in 
them the organisms have played a purely passive role. But 
as we shall have occasion to point out in greater detail later 
on, it does not follow from the existence of the passive carrier 
state that the individual in question may not fall a victim to 
the very organisms that he harbors; in other words, that he 
may not become an active carrier in the sense in which we 
have suggested the use of this term. 

The tremendous influence which the discovery of the 
existence of carriers must have on our future efforts at control 
of the corresponding diseases is, of course, apparent at once, 
and there is scarcely another subject connected with pre- 
ventive medicine that is deserving of so much attention on 
the part of the physician and the public at large as this. For 
this reason it will not be out of place. to consider the problem 
in greater detail in connection with the various diseases in 
the transmission of which carriers have thus far been shown 
to play a role. Their sequence has been arranged so as to 
correspond to the chronological order in which the role of the 
carrier has been established. 



ASIATIC CHOLERA. 

The recognition of the carrier principle in connection with 
the dissemination of various infectious diseases was first 
established by Robert Koch 1 in the course of his well-known 
investigations into the cholera outbreak which occurred in 
Germany during the winter of 1892-93. In his report to the 
Government he relates how at the beginning of the Hamburg 
epidemic, largely in consequence of inadequate assistance, 
the bacteriological work in connection with the situation was 
confined practically exclusively to the study of the dejecta 
of such individuals as were manifestly suffering from the 
disease, or of such as presented clinical symptoms suggestive 
of cholera. It was noted at that time that, notwithstanding 
the isolation of actual cholera patients and clinical suspects, 
additional cases appeared nevertheless in the same surround- 
ings. A case in point will illustrate this. On January 8, 
2 cholera cases were sent to the hospital, from the Spanish 
steamer "Mureiano," which was tied up at one of the docks. 
On investigation 4 additional cases were found among the 
crew, and these also were isolated. The vessel was then 
moved to another part of the harbor and disinfected. She 
here lay close to the steamship "Gretchen Bohlen," which had 
arrived on January 5, and whose crew not only had been 
free from cholera, but had not even been exposed. The 
"Mureiano" came alongside on January 12 and on the 15th 
the disease appeared among the crew of the "Gretchen." The 
inference, of course, was that in spite of the removal of the 
clinical suspects, and the disinfection of the vessel, members 
of the latter's crew, even though not ill themselves, must have 
harbored the corresponding organisms, which no doubt 
found their way into the water alongside the ship through 
the flush closets, and were then dipped up by members of the 
negro crew of the "Gretchen," who used the harbor water not 
only for washing the decks, but for drinking purposes as well. 



22 ASIATIC CHOLERA 

On the basis of observations such as this, Koch then 
insisted upon an extension of the quarantine to contacts, and 
the bacteriological examination of their dejecta, irrespective 
of the existence of clinical symptoms and the character of 
the stools. It was then found that cholera bacilli could occur 
not only in the dejecta of individuals presenting but slight 
symptoms of indisposition, but even in those of apparently 
healthy persons, who had been in contact with cholera 
patients, to be sure, but who had nevertheless been free and 
remained free from any clinical evidence of the disease. In 
other words they were healthy carriers. The discovery of such 
a possibility afforded an immediate explanation of the appa- 
rently mysterious manner in which secondary outbreaks of the 
disease had occurred in different places, where cholera had 
previously not existed. Outbreaks of this order had been 
cited as a matter of fact as evidence in favor of the view that 
Koch's bacillus had in reality nothing to do with the disease, 
for it was argued, that inasmuch as cholera could be intro- 
duced by perfectly healthy individuals coming from a cholera 
focus to a community which had hitherto been free from 
the disease, the latter could scarcely be caused by the 
organism in question, the supposition being that the bacillus 
could not exist in individuals who themselves were not 
suffering from the malady. 

The discovery, however, that this was possible, changed 
all this and made clear many points which heretofore had 
been wrapped in complete obscurity. Various important 
problems now suggested themselves for investigation. It 
was thus essential to ascertain how long the bacilli could 
maintain themselves in the intestinal tract after the disease 
had clinically come to an end ; whether or not their virulence 
remains unimpaired; the frequency of carriers with symp- 
toms so mild as not to suggest the existence of cholera; the 
frequency of the carrier state in apparently healthy persons 
and its duration ; the habitat of the organisms in the carrier ; 
the manner of transmission of the organisms to others; the 
relative menace of the carrier as compared with the cholera 
patient; the question of treatment, etc. 



ACTIVE CARRIERS 23 

Active Carriers. — As regards the first question, viz., the 
length of time that the cholera bacilli may persist in the 
intestinal tract, it appears from the available data that this 
almost invariably is brief. Guttmann 2 thus reports that in 
3 of his 10 cholera convalescents the organisms were demon- 
strable only to the fifth day, in 2 to the seventh, in 2 to the 
eighth, and in 2 others to the ninth and in 1 to the tenth day. 

Simonds 3 found them in every case that came to autopsy 
up to the sixth day; between the seventh and twelfth in 50 
per cent, of the cases; exceptionally only after the twelfth 
day, and in only one instance as late as the eighteenth day. 
Rumpel 4 studied 117 typical cases and could not find the 
bacilli after the twenty-fourth day; he noted also that in 
mild cases they disappeared rather earlier than in severe 
cases, the latest between the eighteenth and the twentieth 
days. Very painstaking examinations with technically 
perfect methods have further been recorded by Kolle. 5 This 
observer reports that irrespective of the severity of the 
clinical picture the vibrios in the majority of cases are no 
longer demonstrable even with the delicate peptone method 
(see below) between the tenth and the twelfth day. Fre- 
quently the cultures were negative already on the seventh or 
eighth day, and in only 6 of 50 cases did the carrier state 
extend over the twentieth day. In one single instance, how- 
ever, the organisms were demonstrable yet on the forty-eighth 
day. With the exception of a single observation by Donitz, 6 
in which a positive culture was obtained on the forty-ninth 
day, the last-mentioned case represents the longest period of 
time during which cholera vibrios have been demonstrable 
in the feces of a cholera convalescent. 

Corresponding results have been obtained by Lazarus and 
Pielicke, 7 Michailow, 8 Rommelaere, 9 Abel and Claussen, 10 
Greig 14 and others. 

As regards the relative number of cholera convalescents 
who still harbor bacilli after clinical recovery has taken place 
Greig reports that of 30 patients who had been inmates in 
the cholera hospital of Puri, India, 11, i. e., 3.6 per cent., were 
still excreting the corresponding organisms in the stools at 
the time of their discharge. 



24 ASIATIC CHOLERA 

Passive Carriers. — While the carrier stage in cholera con- 
valescents is usually quite temporary and only exceptionally 
extends beyond the second week, and while the quarantine 
problem in the case of individuals who are known to have 
passed through an attack of the malady is thus relatively 
simple, we must not forget that the organisms in question 
may also be harbored by persons who are apparently in good 
health, but who have been in contact with cholera patients, 
and it is this class of individuals that interests us particularly, 
as they are manifestly a grave menace to others and represent 
potential foci for the development of outbreaks of the disease 
in districts in which cholera has previously not existed. As 
yet but little is known of the relative frequency with which 
normal individuals may become carriers of this order. As I 
have, already pointed out, nothing at all was known of the 
possibility of such an occurrence until the German epidemic 
of 1892-1893 had already passed its climax, and since that 
time the number of observations that could be made with 
adequate bacteriological methods was, in Germany at least, 
relatively small. Pfeiffer 11 examined the various members 
of a family of ten, in which cholera had appeared, and found 
three carriers of this type. Frosch 12 refers to a study of 42 
infected individuals among which 16 were healthy carriers, 
and emphasizes that of these 12 were children. Friedheim 13 
further reports that of 292 individuals in whose stools cholera 
vibrios were found 51 were apparently perfectly well. During 
the minor epidemic which occurred in Germany also, in 1905, 
and at a time when the importance of examining the stools 
of all contacts, whether they appeared well or otherwise, was 
already fully realized, an examination of 212 infected persons 
revealed the presence of 38 healthy carriers. If then we sum 
up these data we find that of 561 infected individuals 108, 
i. e., 19.2 per cent., showed no clinical evidence of disease, or, 
in other words, that for every 453 actual patients or conva- 
lescents, there were 108 individuals who excreted cholera 
vibrios in their stools without themselves knowing of the 
danger which they represented to others, and without being 
suspected, until a bacteriological examination revealed the 
true state of affairs. While it has been shown that carriers 



RELATION OF CHOLERA CARRIERS TO DISEASE 25 

of this type do not harbor the organisms any longer than 
individuals who have actually passed through an attack of 
the disease, that they also are temporary carriers only, they 
nevertheless represent a most formidable menace to the 
community as long as the condition lasts. 

Virulence of Organisms. — While I have not been able to find 
any direct statements regarding the virulence of the organ- 
isms occurring in healthy carriers, the findings in cholera 
convalescents may, I think, be properly applied to the former 
as well, and these have proven conclusively that so long as 
the organisms can be isolated from the intestinal contents 
their virulence is practically constant. 5 

Relation of Cholera Carriers to Outbreaks of the Disease. — 
Koch has repeatedly mentioned that it is frequently impos- 
sible to trace an outbreak of cholera to a single individual, 
even if that individual has himself passed through an attack 
of the disease. As the organisms may persist in the intestinal 
tract for as long as seven weeks, it is conceivable that a person 
may pass through a mild attack in one country without him- 
self realizing the true nature of the ailment, and before the 
expiration of the carrier stage to arrive at a place thousands 
of miles away and there to become a primary focus of infec- 
tion with the rapid development of secondary foci and the 
resultant outbreak of an epidemic. It is clear that under 
such conditions the most careful investigation might not 
reveal the actual source of the outbreak. By the time that 
the community has come to a realization of the true nature of 
the disease, the individual in question may indeed have passed 
the carrier stage and have already left for other parts. This 
being so, it will readily be understood that it may be even 
more difficult to trace an outbreak to a passive carrier, i. e., 
one who has never been ill. But even so, there are a number 
of instances on record in which the chain of evidence is 
sufficiently strong as to definitely connect the development of 
cholera outbreaks with carriers of this order, and to demon- 
strate what a formidable menace such people represent, so 
long as they are permitted to remain at large, particularly 
as they themselves have no knowledge of their condition. 



26 ASIATIC CHOLERA 

Examples Illustrating the Activity of Carriers. — In this con- 
nection an outbreak of the disease in the insane asylum at 
Nietleben, near Halle, is of special interest. 1 This began in 
the middle of January, 1893, at a time when the European 
epidemic was confined to Russia, France, and so far as 
Germany went, to Hamburg-Altona. During this outbreak 
122 cases of the disease developed in the institution. Its 
origin was investigated with great care. As no persons con- 
nected with the institution had come from foreign parts, it is 
evident that the Hamburg-Altona district was the only one 
that could enter into consideration as its source. An investiga- 
tion of the food supply did not furnish any evidence that the 
disease was introduced in this manner, as the hospitals of the 
neighboring city of Halle were supplied by the same dealers, 
and no cases occurred there; and as cases of the disease also 
developed among individuals who did not receive their board at 
the institution. A soil origin which in those days was thought 
to play a role could also be excluded, since the buildings all 
stood upon a rock foundation. An examination of the sewer- 
age, however, revealed the presence of cholera vibrios and 
these could also be demonstrated in the water of the river 
into which the sewerage emptied after passing through the 
disposal plant. The drinking water was obtained from the 
same river at a point below the entrance of the supposedly 
purified sewerage. This water was passed through filters, 
it is true, but as Koch could show, one of these was evidently 
in imperfect condition or improperly managed, as the organ- 
isms could be demonstrated in the water immediately after its 
passage through this filter, as well as in a specimen obtained 
from one of the spigots in the institution. 

It was thus clear that with a cholera focus in the institution 
the organisms would be distributed from this focus through 
the sewerage and the drinking water supply to the inmates 
at large. The question then which remained for solution was 
how that focus developed; in other words, who the individual 
was who introduced the organisms. As the patients all came 
from the province of Saxony, and as cholera had not occurred 
there, this source could be eliminated, unless we assume the 
very unlikely event that a carrier had travelled from Ham- 



EXAMPLES OF THE ACTIVITY OF CARRIERS 27 

burg to Saxony, and had there infected an individual who 
soon after came to the institution as a patient. More likely 
is the possibility that the disease was introduced by an 
employee who was newly engaged. Investigation showed 
that within the three months preceding the outbreak of the 
disease thirteen new attendants had been engaged, but that 
none of these had come directly from Hamburg. One indi- 
vidual, however, who came from Halle, admitted that he had 
lived at the latter place only a few days, and that before that 
he had been in Hamburg. This same individual had suffered 
from severe diarrhea on first coming to the institution. 
While Koch does not regard it as proven by any means that 
this person originated the epidemic at Xietleben, he merely 
cites this case as indicating that a connection did undoubtedly 
exist between Hamburg and Nietleben, and that it is not 
impossible that one or the other of the newly-engaged em- 
ployees had after all been in Hamburg, although engaged 
from Halle, and had possibly purposely neglected to give this 
information. The evidence, of course, is circumstantial, but 
as all other sources could be eliminated, it is only logical to 
conclude that the outbreak was actually due to a carrier, who 
either had never had the disease, or whose attack had been 
so mild that he himself was not aware of its true nature. 

Another interesting outbreak, which was apparently traced 
to a definite individual, has been recorded by Greig. 15 During 
the general epidemic which occurred at Puri in India, in 1912, 
the disease also appeared in the local jail and led to the 
development of 17 acute cases, the first occurring on July 
27. An immediate investigation revealed that on July 23 
a boy aged twelve years had been admitted, who had been 
attacked by cholera on July 6, and had been a patient 
in the cholera hospital from that date to July 13, when he 
was discharged. On July 28, i. e., three weeks after the 
beginning of his attack, this boy's feces were examined and 
cholera vibrios found in large numbers. It is noteworthy 
that the youth had been placed in the "under-trial" ward, 
and that the disease appeared four days later in this same 
ward. 

While positive evidence regarding the menace which the 



28 ASIATIC CHOLERA 

carrier represents to all who come in contact with him is, of 
course, more striking than negative evidence, the latter may 
at times be of almost equal value. Such evidence is afforded 
by the fact that although many cholera carriers reached the 
United States during the past twenty-five years from foreign 
countries, their recognition and isolation at our quarantine 
stations have served as a complete safeguard to our country, 
for not a single instance of the disease has developed during 
that time on United States soil. 

The full extent of the carrier danger we can, of course, only 
surmise. During the Hamburg epidemic of 1892, 18,000 
recognized cases of the disease had occurred between August 
16 and October 23, leading to 8200 deaths. This represents 
the primary outbreak of the disease, concerning the origin 
of which we have no definite knowledge. It may in itself 
have been due to carrier activity. But, however this may 
be, we may properly assume that the secondary epidemics 
which followed the one at Hamburg were certainly, in part 
at least, referable to such a source. To refer these secondary 
outbreaks to the distribution of infected clothing and bedding 
only, would scarcely be warrantable, if we bear in mind the 
very thorough methods of disinfection which were practiced, 
and the nature of the quarantine regulations which were then 
in force. The significance of the carrier, however, it will be 
recalled, was not yet realized until the primary epidemic had 
nearly come to an end, and as the period of quarantine against 
persons coming from the infected district covered only the 
incubation period of the disease, it will readily be understood 
that many avenues for the distribution of the malady by 
carriers really stood wide open. The wonder indeed is that 
the secondary epidemics were not more extensive. But as 
the carrier stage is, after all, of relatively brief duration, this 
factor no doubt, coupled with the regulations which were then 
in force and which became more rigid as the carrier signifi- 
cance was fully realized, was sufficient to prevent a wider 
dissemination of the disease than actually occurred. Sub- 
sequently, when adequate bacteriological examinations of the 
feces of all contacts became the rule, which, of course, meant 
the elimination of the carrier, the disease died out. 



MODE OF INFECTION 29 

Where the carrier goes virtually unchecked, as in India, it 
is natural that the disease will never die out. An endless 
chain is here in operation which will not be broken until the 
carrier problem is solved, and until the frightful danger 
arising from water pollution by cholera carriers is fully 
recognized, and appropriate action taken to prevent mass 
infection through this channel. Hundreds of thousands of 
people gather here from time to time, coming from all parts 
of India; they bathe in and drink the holy water of the 
Ganges, and what wonder that epidemic follows epidemic 
in the cities in which the people have gathered! The con- 
valescent and healthy carriers then return to their homes, 
where they give rise to outbreaks of a minor nature, starting 
new foci, which perpetuate the existence of the organism, 
and thus furnish the material for larger epidemics, whenever 
and wherever local conditions favor their development. 
The religion of the natives is a powerful factor in preventing 
sanitary progress in that country, but in view of the fact that 
many of the native rulers have received a European educa- 
tion, and could use their influence with their countrymen, one 
should imagine that better progress might have been made, 
and that the responsibility for the continued ravages of the 
disease may not be attributed solely to native conditions. 

Mode of Infection. — As regards the manner in which the 
carrier may disseminate the organisms the same possibilities, 
of course, suggest themselves as in the case of the cholera 
patient. As the organisms are present in the intestinal con- 
tents, and as infection can only take place through the diges- 
tive canal, it is clear that any substance which is capable of 
serving as a connecting link between the two is capable of 
conveying the disease. More or less extensive outbreaks will 
naturally occur and indicate their probable origin by the 
explosive nature with which they develop, when the drinking 
water supply of a community becomes infected, and as a 
matter of fact all major epidemics may be regarded as refer- 
able to such a source. Minor outbreaks, on the other hand, 
may be due to contamination of various articles of food, and 
isolated cases possibly to a direct transference of fecal material 
through soiled hands or soiled clothing. 



30 ASIATIC CHOLERA 

Habitat of Organisms. — While the intestinal contents no 
doubt represent the most important medium by far, through 
which the organisms are disseminated, and were long regarded 
as the only excretion in which they occurred, it appears from 
the studies of Greig 16 that they may also appear in the urine 
(urinary carriers) . He relates that he was able to isolate the 
organism from this source in 8 cases out of 55, and that in 2 
of these the patients had already recovered and were going 
about doing their work. In another paper the same writer 
reports that in one case of cholera 17 he could demonstrate the 
presence of the comma bacillus in a pneumonic area which 
implies the possibility of its dissemination through the 
sputum. These observations are of particular interest as 
they prove that cholera, like various other bacterial diseases, 
such as typhoid fever, which were formerly regarded as being 
essentially local infections, may also be a true septicemia. 

Intermittent Elimination. — While the elimination of cholera 
bacilli in the feces is usually continuous, several investigators 
have reported that it may also be intermittent. This is impor- 
tant to bear in mind in connection with the question whether a 
single negative culture may be regarded as evidence that the 
carrier stage has been passed . Evidently such a position is no 
longer tenable. Creel 18 reports the case of a sailor on board a 
transatlantic liner who arrived at New York quarantine with 
the history of having had an attack of diarrhea and vomit- 
ing during the trip. Examination of his feces on August 17 
revealed the presence of cholera vibrios. From that date to 
August 30 all examinations were positive. On August 30 and 
September 1 negative results were obtained. Between August 
30 and September 27, the organism was present on four 
occasions and absent on six. After September 27 all cultures 
were negative. Regarding the cause of the intermittency 
Creel suggests that "gall-bladder infection does not seem 
likely, as cholera is not a bacteremia, and direct infection 
from the intestinal canal does not seem probable. " He there- 
fore assumed that there were residual masses of fecal material 
containing vibrios which were not evacuated. Creel, however, 
evidently was not aware of the fact that several observers 
had previously found that the cholera vibrio does find its way 



INTERMITTENT ELIMINATION 31 

into the gall-bladder, and that similar conditions thus exist 
as in typhoid fever, where, as we now know, the gall-bladder 
is involved in every case and probably represents the sole 
focus from which the bacilli in fecal carriers at any rate find 
their way into the intestinal canal. Nicati and Rietsch 19 
in 1884 already had reported the presence of cholera vibrios 
in the bile in 2 cases of the disease out of 3, and on a later 
occasion in 2 out of 5. Similar findings have been published 
by Doyen, 20 Tizzoni and Cantoni, 21 Raptschevsky 22 and 
Rekowsky,^ and still more recently by Kulescha, 24 Bruloff, 25 
Defressine and Cazeneuve, 26 Greig 27 and Crowell and John- 
ston. 28 Kulescha found cholera vibrios in the gall-bladder in 
49 cases out of 109 and definite anatomical lesions in the 
biliary passages in 10 per cent, of the cases. Bruloff reports 
the presence of the vibrios in the bile in 76 per cent, of the 
cases and speaks of their occurrence in the blood and other 
organs. Greig examined 271 cases and found vibrios in the 
bile of the gall-bladder in 81, i. e., in practically 30 per cent. 
In 68 of these no pathological changes were observed in the 
biliary passages although the comma bacillus was present in 
pure culture. Iu others, however, the walls were distinctly 
diseased. Crowell and Johnston obtained positive cultures 
from the bile in 65 per cent, of their cases of the actual dis- 
ease, while of 32 carriers who were detected postmortem the 
bile was positive in 75 per cent., and it is noteworthy that 
in 43 per cent, of the carriers the intestinal contents gave a 
negative result, while the bile was positive. 

That the organism reaches the gall-bladder through the 
blood stream is, of course, the most logical assumption, in 
view of Greig's findings, as well as those of Bruloff, referred 
to above, and is further supported by the experiments of 
Baroni and Ceaparie Victoria. 29 These investigators injected 
cholera vibrios into the ear vein of a rabbit, and found them 
in the bile thirty minutes later, where they remained demon- 
strable for one hour after the injection. 

Like Creel, Greig 15 also found that the elimination of the 
vibrios may be iutermittent. In 2 of his 11 cases in which 
the elimination was especially prolonged, there were long 
intervals — in one instance sixteen days — during which the 
organisms were not demonstrable. 



32 ASIATIC CHOLERA 

All these observations are quite analogous to what is known 
to occur in typhoid fever. The important question, of course, 
remains whether in those individuals in whom the vibrios 
persist for a longer time than the average, and particularly 
in those in whom the elimination is intermittent, infection 
of the gall-bladder is the responsible factor. To judge from 
the numerical results obtained by Crowell and Johnston this 
seems to be the case (see above). 

As in the case of typhoid fever it would appear that the 
cholera vibrio also cannot maintain itself for any length of time 
outside of the human body, and that the elimination of the 
carrier would therefore lead to the eradication of the disease. 

Recognition of Cholera Carriers.— As cholera carriers can 
only be recognized by adequate laboratory examinations, 
these are indicated in every individual coming from a focus 
where cholera is or has been in existence within the period of 
time that the organisms are known to be able to maintain 
themselves in the human body, viz., nine weeks. This may, of 
course, entail an immense amount of labor, but from the 
results that have been reached it is clear that no other method 
is applicable, and that the work is hence necessary. At the 
New York quarantine station 34,000 fecal specimens were 
examined during the summer of 1911, the necessity for which 
is apparent from the fact that the cholera vibrio was found 
in 27 healthy persons, who would have been allowed to pass 
quarantine with results that can hardly be in doubt, had 
it not been for the findings in their stools. Corresponding 
examinations were made at Boston and Providence which 
were the only other ports having direct Italian immigration. 
As a result, not a single case of the disease developed in the 
United States, notwithstanding the constant steamer con- 
nection with infected ports in Europe. 30 During the same 
period of time 7338 travellers from suspected ports on the 
Baltic were examined at Rotterdam and Amsterdam, and 
7 cholera carriers found. At Naples 2000 emigrants were 
examined and 12 carriers discovered. In Egypt an examina- 
tion of 15,000 persons from suspected ports led to the finding 
of 22 carriers, and so on. It is clear that the labor is great 
and will necessitate the cooperation with the usual authori- 



RECOGNITION OF CHOLERA CARRIERS 33 

ties at critical times of municipal and other laboratories, and 
the training of the men in these in the laboratory diagnosis 
of this type of carrier. 

Technic. — As regards the technic involved it has been 
suggested that the individual under examination be given a 
dose of castor oil previous to the collection of a sample of his 
feces, with the idea in mind, not only of increasing the 
number of organisms eliminated, but especially of bringing 
organisms to elimination during a period of natural inter- 
mission. But as this has not proven successful such prepara- 
tory treatment may well be omitted. An ordinary specimen 
only needs to be procured. 

The early work in the search for cholera vibrios in the feces 
was done by smearing gelatin plates from an emulsion of a 
loopf ul of the material in question in a few cubic centimeters 
of bouillon, and allowing growth to proceed at room tem- 
perature for about twenty-four hours. Smears were then 
made from suspicious-looking colonies, which are strongly 
refracting, yellowish-gray in color and of pin-head size, show- 
ing a tendency to liquefy the gelatin, and after staining with 
the usual dyes examined in reference to the morphology of 
the organism, which is a vibrio and hence appears as a small 
curved rod, varying from one to two micra in length. 

This method is quite serviceable when the organisms are 
not present in too small a number, but as the latter is of fre- 
quent occurrence, it has been found more advantageous to 
plant a small amount of fecal material — from 1 to 4 or 5 c.c. 
— in a flask containing about 250 to 300 c.c. of Dunham's 
peptone 1 solution which serves as enriching medium, permit- 
ting the more rapid development of the cholera vibrios than 
of the accompanying bacteria. After incubating for six hours 
at 37° C. a small quantity of the culture is taken from near 
the surface, transferred to a second flask of the same medium 
and incubated for about twelve hours longer. If smears from 
near the surface of this second growth now reveal no vibrios 
the examination is recorded as negative. If vibrios are found 

1 Dunham's solution contains 10 grams of peptone and 5 grams of salt 
dissolved in a liter of water by the aid of heat. The solution is filtered and 
sterilized by the fractional method. 
3 



34 ASIATIC CHOLERA 

ordinary agar plates are smeared from the peptone solution 
culture, incubated over night, and suspicious-looking colonies 
fished the next day, and examined with an anticholera serum 
of high titer (1 to 10,000 to 1 to 15,000), using a dilution 
of 1 to 500 and the microscopical test. If the macroscopic 
method is to be employed, subcultures from the plates are 
made on agar slants, and these incubated for a period of time 
sufficient to furnish the necessary amount of material, which 
is then emulsified and mixed with a suitable quantity of an 
agglutinating serum, so as to give a dilution of 1 to 500. 
Controls with normal serum in the same dilution must, of 
course, also be prepared. A positive result is indicated by the 
occurrence of instantaneous agglutination, as evidenced by 
distinct curdling. 

If desired, the organism can be further studied bacterio- 
logically and biologically — in reference to its virulence, for 
example — but for practical purposes the above procedure 
is sufficient. 

Release of Carriers. — A single negative result is, of course, not 
sufficient to release an individual coming from an infected dis- 
trict from quarantine, as the elimination of the organisms not 
infrequently is intermittent. To meet this difficulty the only 
safe procedure would be to hold such persons until repeated 
examinations covering the period of maximum intermittent 
latency, viz., twenty-one days (Greig) have shown that the 
organisms are in reality absent. The quarantine regulations 
which are actually in force are not as stringent as this and 
at most, if not all stations, a carrier would be released, if the 
cultures from the stools gave two negative results at three 
or four examinations, at intervals of three or four days. 

El Tor Carriers. — While the demonstration in the feces of the 
presence of vibrios, which are agglutinated by a specific anti- 
serum of high titer, in a dilution of 1 to 500, as has been advised 
above, unquestionably represents sufficient grounds for quaran- 
tining the corresponding individual as a carrier, it is well to 
bear in mind that vibrios have been found in the stools of indi- 
viduals who have not passed through an attack of the disease, 
nor have come from a cholera district, which culturally as 
well as in their behavior toward cholera antiserum cannot be 



EL TOR CARRIERS 35 

distinguished from true cholera bacilli. Belonging to this 
order is the so-called El Tor vibrio, so named from its dis- 
covery at the El Tor quarantine station among pilgrims 
returning from Mecca. The organism was found at a time 
when cholera did not exist either at Mecca, nor among the 
pilgrims at El Tor. Its true status has given rise to much 
speculation, and while certain differences exist between it and 
the cholera vibrio, these differences are of such a nature that 
they could not be utilized in the study of large numbers of 
people at quarantine stations, let alone in places where 
cholera is actually existent. From a practical standpoint 
these El Tor carriers should be treated exactly as the cholera 
carriers, i. e., they should be quarantined until the organisms 
have disappeared from the feces. 

Aside from the El Tor vibrio, other vibrios have been 
described as occurring in the stools of cholera convalescents 
and contacts and at times alternating with the true cholera 
vibrios, but differing from these in the fact that they are not 
agglutinated by anticholera serum of high titer while they 
may be agglutinated by the person's own serum. 15 28 The 
status of these organisms also is as yet an open one, but inas- 
much as they have thus far been observed in cholera conva- 
lescents and contacts only, it may be just as well to extend the 
quarantine period of such individuals until these organisms 
also have disappeared. 

In conclusion I would briefly refer to the suggestion that in 
place of the fecal examination a serological examination of all 
cholera suspects be made and that the former be resorted to 
only when the latter shows that an individual's serum gives 
an agglutinative reaction with a standard strain of the 
cholera vibrio. It has been shown as a matter of fact that 
the blood serum of cholera carriers does contain agglutinins. 
Greig 15 thus mentions that even in the 2 carriers with long 
periods of intermittency (sixteen to twenty-one days), which 
he had occasion to study with special care, agglutination was 
obtained, while all the others who did not show the comma 
bacillus in their stools gave a negative result. Analogous 
results have been reported by Massaglia. 31 As yet our infor- 
mation on this point is too meager, however, to warrant the 



36 ASIATIC CHOLERA 

substitution of the serological for the direct bacteriological 
method. In order to come to a conclusion the two exami- 
nations should be made side by side in a large series of cases, 
and for this work we no doubt will have to look to our 
colleagues in the East. Meanwhile the bacteriological 
examination of the feces should be relied upon at the various 
quarantine stations. 

Management of Cholera Carriers. — Quarantine. — As it is 
absolutely essential that no cholera carrier should be per- 
mitted to be at large, it follows that at times of epidemics no 
convalescent should be discharged from observation until 
repeated examinations of his feces have proven that he no 
longer harbors the organisms, and that every contact be 
quarantined and examined in the same manner. Bearing 
in mind the occurrence of intermissions in the elimination of 
the organism it would further seem indicated that the 
quarantine be maintained until repeated examinations over 
a period of three weeks have shown only negative results, 
unless indeed the individual has actually been removed from 
the focus of infection for a period of seven weeks, in which 
case a single negative examination would suffice to warrant 
his release. In other words, so far as quarantine is concerned 
the carrier should be treated exactly as a case of the actual 
disease. Upon his release he should be kept under surveil- 
lance for a reasonable length of time, and in the event of his 
wishing to change his place of abode to another town the 
authorities at that place should be notified of his coming 
and the individual be ordered to report himself immediately 
upon his arrival. These regulations are actually in force in 
our country, and coupled with adequate laboratory control 
have furnished complete protection. 

BIBLIOGRAPHY. 

1. Koch, R. : Die Cholera in Deutschland wahrend des Winters 1892 
bis 1893, Ztschr. f. Hyg., 1893, vol. xv, p. 89. 

2. Guttmann: Deutsch. med. Wchnschr., 1892, vol. 18, p. 842. 

3. Simonds, M.: Ibid., p. 1173. 

4. Rumpel: Berl. klin. Wchnschr., 1894, No. 32. 

5. Kolle, W. : Ueber d. Dauer d. Vorkommens v. Cholera Vibrionen in 
den Dejekten. v. Choleraconvaleszenten, Ztschr. f. Hyg., 1894, vol. xviii, 
p. 42, 



BIBLIOGRAPHY 37 

6. Cited by Pfeiffer, R. : Die Verbreitung d. Cholera durch sogenannte 
Dauerausscheider und Bazillentrager. Klin. Jahrbuch., vol. xix, p. 485. 

7. Lazarus and Pielicke: Bericht iiber d. bakteriol. Untersuchungen 
b. Cholera- u. choleraverdachtigen Erkrankungen in Berlin. Berlin klin. 
Wchnschr., 1892, vol. xxix, p. 1215. 

8. Michailow, Bolritschnaja Gaseta Botkina, 1892, Nos. 45 and 51. 

9. Rommelaere: Jour, de med. de Bruxelles, 1892, No. 49. 

10. Abel and Claussen: Untersuch. iiber d. Lebensdauer d. Cholera- 
vibrionen in Faekalien, Centralbl. f. Bakt. u. Parasitenk., 1895, vol. xvii. 

11. Pfeiffer, R. : Die Cholera im Oderstromgebiete, Monograph, p. 47. 

12. Frosch: Die Cholera im Gebiete d. Netze, Warthe and Oder im 
Jahre 1894. Monograph. 

13. Friedheim: Das Auftreten d. Cholera im Deutschen Reiche wahrend 
d. Jahres 1893 and 1894. 

14. Greig, E. D. W. : An Investigation of an Epidemic of Cholera Caused 
by a Carrier, Indian Jour. Med. Research, 1913-14, vol. i, p. 59. 

15. Idem: Cholera Convalescents and Contacts, ibid., p. 65. 

16. Idem: On the Occurrence of the Comma Bacillus in the Urine in 
Cases of Cholera, ibid., p. 90. 

17. Idem: The Cultivation of the Comma Bacillus from the Lung in a 
Case of Cholera, ibid., p. 270. 

18. Creel, R. H.: An Unusual Cholera Carrier, Jour. Am. Med. Assn., 
1912, vol. lviii, p. 187. 

19. Nicati and Rietsch: Recherches sur le cholera, Arch, de Physiol, 
norm, et pathol., Paris, 1885. 

20. Doyen: Compt. rend, de la Soc. de biol., 1884, No. 42, and Le 
Progres med., 1885, No. 27. 

21. Tizzoni and Cantoni: Centralbl. f. d. med. Wchnschr., 1886, No. 43. 

22. Raptschevsky, J. F.: Wratsch, 1886, No. 45. 

23. Rekowsky, L. P.: Arch. d. sciences biol. de St. Petersburg, vol. i, 
p. 1892. 

24. Kulescha: Centralbl. f. Bakt., 1909, vol. lix, orig., H. 4. 

25. Bruloff, L.: Wratsch, 1910, p. 1821. 

26. Defressine, C, and Cazeneuve, H.: Manual of Bakteriology, Muir 
and Ritchie, 1910. 

27. Greig, E. D. W. : An Investigation on the Occurrence of the Cholera 
Vibrio in the Biliary Passages, Indian Jour. Med. Res., 1913-14, vol. i, p. 44. 

28. Crowell, B. C, and Johnston, J. A.: Bacteriological Investigations 
of Feces and Bile of Cholera Cases and Cholera Carriers, Philippine Jour. 
Sc, 1917, sec. B, vol. xii, p. 85. 

29. Baroni and Ceaparie Victoria: Compt. rend, de la Soc. de biol., 
1912, vol. lxxii, p. 894. 

30. Anderson, J. F. : Some Recent Contributions by the U. S. Public 
Health and Marine Hospital Service to Preventive Medicine, Jour. Am. Med. 
Assn., 1912, vol. lviii, p. 1748. 

31. Massaglia: Soc. med. chir. di Modena, Meeting of October 2, 1911. 



DIPHTHEEIA. 

Active Carriers. — Following the announcement by Escherich 1 
in 1890 that he had found diphtheria bacilli in the throats 
of convalescents from the corresponding disease, during the 
first three days after the disappearance of the membrane, 
the question naturally arose for how long a time such indi- 
viduals could remain a menace to others. This problem has 
been widely investigated and the conclusion reached that the 
organisms may not only persist for a number of days follow- 
ing clinical recovery, but for weeks and months and even 
for years; in other words, that the diphtheria patient may 
become a carrier of variable duration. One of the most exten- 
sive investigations in this direction was conducted by the 
Health Department of New York City in 1893-1894, under 
the direction of Biggs, with the assistance of Park and 
Beebe. 2 An analysis of 752 cases, which were studied with 
reference to the length of time that the organisms may remain 
in the throat, showed the following: In 325 cases, i. e., in 
43.2 per cent., the bacilli disappeared within three days 
after the complete disappearance of the exudate; in 427 
cases, i. e., in 56.8 per cent., they persisted for a longer 
time, viz. : 



In 201 


i. e. 26.7 per cent. 


for 5 t 


o 7 days 


84 


i.e. 11,1 


" 


12 " 


69 


i.e. 9.1 


" 


15 " 


57 


i.e. 7.5 


" 


3 weeks 


11 


i.e. 1.4 


" 


4 " 


5 


i.e. 0.6 


" 


5 " 



Another large series of cases was investigated during 1900 
by Prip. 3 The organisms could here be demonstrated in 
345 out of 654 cases, i. e., in 52.7 per cent., while the mem- 
brane persisted in the fauces ; whereas in the remaining 309 



ACTIVE CARRIERS 



39 



cases, i. e., in 47.3 per cent., they were present for a longer 
period of time, viz. : 



In 118 
93 
51 

41 
4 
2 



i. e. 18.0 per cent, for 1 to 10 days 
i. e. 14.8 " " 10 to 20 ' 

i. e. 7.7 " " 20 to 30 

i. e. 6.2 " " 30 to 60 

i. e. 0.6 " " 60 to 90 

i. e. 0.3 " " 90 to 120 



Tjaden 4 has reported examinations in 1338 cases, which 
were carried on until the bacilli had disappeared, with the 
following results: 



In 897 cases, i. e. 


67.0 per cent, the organisms were gone after 2 weeks 


1004 ' 


' i. e. 


75.0 




1 " ' 


' 3 " 


1109 < 


' i. e. 


83.6 




' " ' 


t 4 u 


1192 ' 


' i. e. 


89.1 




< u i 


' 5 " • 


1248 ' 


' i. e. 


93.4 




1 " ' 


' 6 " 


1297 ' 


' i. e. 


96.9 




< u t 


' 7 " 


1303 ' 


' i. e. 


97.4 




I «« i 


t g u 


1329 ' 


' i. e. 


99.3 




t it I 


' 9 " 


1331 < 


' i. e. 


99.5 




t " < 


' 10 " 


1336 ' 


' i. e. 


99.9 




I U I 


t n tt 


1337 ' 


' i. e. 


99.95 




t It t 


1 14 " 


1338 ' 


' i. e. 


100.0 




t It < 


' 17 " 



Similar findings have been published by Glucksmann, 5 
Scheller, 6 M. Neisser and Heymann, 7 E. Neisser and Gabriel, 8 
and many others. From the collected data we may conclude 
that approximately 85 per cent, of diphtheria convalescents 
are free from bacilli by the end of the fifth week, and 98 per 
cent, by the end of the ninth week; or, in other words, that 
15 per cent, of the cases harbor the organism even after the 
fifth week and 2 per cent, after the ninth week. But there 
is evidence to show also that exceptionally the bacilli may 
persist in the throat (or nose or both) for a much longer time. 
Hewlett and Nolan 9 have thus reported a case in which they 
were found after six months. Fibiger 10 demonstrated them 
in one case after nine months and Le Gendre and Pochon 11 
after eighteen months. Prip 3 mentions a case in which they 
were found after four years, and Neisser has described an 
instance of chronic nasal diphtheria in which he could isolate 
the organisms after eight years. 



40 DIPHTHERIA 

There is thus abundant evidence to show that the diph- 
theria patient may become a diphtheria carrier, and while 
in the majority of cases this condition is of relatively brief 
duration, it may last sufficiently long, in a not inconsider- 
able percentage of cases, as to warrant the classification of 
such individuals as chronic carriers. The significance of this 
discovery will become apparent at once, if we apply the figures 
given above to conditions as they actually exist in any one 
of our large cities at the present time. During the twelve 
months ending November 30, 1915, there occurred in greater 
New York 15,402 cases of diphtheria. On a minimum basis 
of 15 per cent, it would follow that 2310 cases were thus in 
the carrier stage for a period exceeding five weeks. I say 
"a minimum" advisedly, for this figure does not include 
those cases in whom the carrier stage persists for a longer 
time than twelve months, nor those who have become carriers 
without ever having suffered from the disease. 

Passive Carriers. — That the latter occurrence is possible, 
and indeed very common, is now well known. Loeffler 12 in 
his first publication had already mentioned the fact that in 
the course of an examination of twenty children he found 
bacilli which were morphologically and biologically indis- 
tinguishable from true diphtheria bacilli in the throat of a 
child, notwithstanding the fact that this one had never suffered 
from the disease and was, to all intents and purposes, per- 
fectly well at the time, This observation was for some time 
indeed referred to by his opponents as evidence against 
the etiological relationship of the organism to the disease in 
question. Subsequent investigations showed, however, that 
such an occurrence is by no means rare, and that the organ- 
isms in question are actually diphtheria bacilli, presenting 
all the characteristics of those that may be isolated from 
actual cases of the disease. The majority of cases of this 
order are represented by persons who have been in contact 
with diphtheria patients. In a series of forty-eight children 
who had been in more or less intimate contact with the 
disease, Park thus found bacilli in 50 per cent., though it is 
to be noted that conditions in these particular families were 
the best possible for the transmission of the bacilli from one 



PASSIVE CARRIERS 41 

to the other. But even in families where the isolation of the 
patient had been satisfactorily carried out, the organisms 
were found in a fair number of the other children. Park 
mentions that this was the case in less than 10 per cent., 
but even so it will be realized that on an 8 per cent, basis, 
and allowing three children to a family (two well to one 
actually sick), and applying the 15 per cent, carrier basis to 
the resulting number, our actual number of carriers would 
be increased by 369, giving a total of 2679. But even this 
number,. conservative as it is, is as yet too low, for there still 
remain to be added those carriers who have not developed 
from any known contact with actual cases but from other 
carriers. Regarding the frequency of such cases, Park also 
has furnished us with definite information: Of 280 children 
in New York who gave no history of direct contact with 
diphtheria, eight were found to harbor true virulent diph- 
theria bacilli in their throats, which would correspond to 2.8 
per cent. This, calculated for the entire child population of 
Greater New York, would give us truly a most formidable 
number to which there would still have to be added a not 
inconsiderable number of adult carriers, who have neither 
had the disease themselves nor been in contact with cases 
of the disease. Park, himself, concludes from his studies 
that virulent diphtheria bacilli are present in probably about 
1 per cent, of all healthy throats in New York City! This 
figure agrees very closely with the findings of Goldberger, 
Williams and Hachtel 32 who found thirty-eight carriers in 
the course of an examination of 4093 healthy individuals, 
which gives a percentage of 0.9. 

The conclusions reached by Park have been confirmed by 
practically all observers who have had the opportunity to 
investigate large series of suspects. Vogt 13 and Johannesen 14 
each found diphtheria bacilli in 3 out of 26 apparently healthy 
children; E. Miiller 15 in 24 out of 100. Stenmeyer 16 reports 
that in the course of his investigations in Rotterdam he found 
7 per cent, of the people harboring diphtheria bacilli in the 
absence of any corresponding lesion. Kober 17 examined 600 
healthy school-children and found virulent diphtheria bacilli 
in only 5, and avirulent organisms in 10. Scheller 6 states 



42 DIPHTHERIA 

that in his large series of examinations positive findings were 
recorded in 38 per cent, of the healthy entourage of diph- 
theria patients, and he adds that he regards even this figure 
as too low, since it is based on single examinations only. 
Sommerfeld 18 found bacilli in 8 children out of 368 in a 
general hospital, viz., 2.1 per cent., while Beck 19 and Fibiger, 20 
on the other hand, failed to find diphtheria bacilli in 66 
and 82 healthy individuals, respectively, in whom contact 
with diphtheria could be definitely excluded. As a matter 
of fact there is sufficient evidence to warrant the con- 
clusion, that among people who have never, not even 
remotely, been in contact with actual cases of the disease, 
diphtheria carriers are very rare, and that there is nothing 
tangible to support the view that the organism is more or 
less ubiquitous, as was formerly believed. 

Regarding the frequency of diphtheria carriers among the 
entourage of diphtheria patients in military life, Labit 33 men- 
tions that in his experience the average was 28.9 per cent., 
and that frequently the 50 per cent, mark was reached. 
He relates that on one occasion a single case of the dis- 
ease gave rise to nineteen carriers among the nurses and 
attendants, and that these in turn produced others in such 
numbers that it became necessary to isolate the physically 
fit of the entire unit and to give them employment as gar- 
deners and the like. McCord, Friedlander and Walker, 34 
on the other hand, who conducted their investigations at 
Camp Sherman, found that of 3215 exposed persons only 
2.76 per cent, were what they term contact, viz., passive 
carriers. Such wide differences can, of course, be explained 
in part on the basis of the much more favorable conditions 
under which our national army recruits lived during their 
period of training in this country, as compared with those 
which must exist among actual fighting units. Bat even so, 
remembering the overcrowded condition of the camps and 
base hospitals, during the past winter, it is surprising that 
such a low carrier incidence should have existed. The 
observers last mentioned remark that, if corresponding 
figures should be obtained at other camps, it is permissible 
to maintain that diphtheria is not a major camp disease, 



HABITAT OF ORGANISM 43 

and that the occurrence of sporadic cases is not a matter 
of special gravity. With this view other observers do not 
agree. Keefer, Friedberg and Aronson, 36 while stationed at 
Camp Doniphan, thus report that "during the early months 
of 1918 the control of diphtheria, with special reference to the 
carriers of the disease, was a very serious problem which for 
a long time seemed but little influenced by the strenuous 
efforts of the staff." During a period of four months 461 
cases of clinical diphtheria and 686 carriers were observed. 
" Even at a time when but few cases of the actual disease were 
under treatment more than half of the twenty-six wards of 
the hospital contained carriers among patients and atten- 
dants. And although cultures were made of all in such wards 
and infected individuals removed, the next search, at an 
interval of from five to seven days, was sure to reveal at 
least as many more who harbored the organism." 

Habitat of Organism. — As in the case of various other 
pathogenic organisms there is steadily increasing evidence 
to show that the normal and exclusive habitat of the diph- 
theria bacillus is the diphtheria patient and the diphtheria 
carrier. In both, moreover, it is exclusively the mucous 
membrane of the nose, the throat and the mouth, with the 
communicating structures, which enter into consideration. 

In the great majority of cases the carriers harbor the bacilli 
in the tonsils. In a small number the organisms are found 
only in the nose and in the most persistent carriers of this 
type chronic inflammatory or atrophic processes are almost 
invariably demonstr.able. 36 

The middle ear is apparently infected in many cases of 
the disease and it is noteworthy that this frequently occurs 
at a time when the patient has, apparently, already entered 
upon the stage of convalescence. Wolff 21 mentions that in 
nasal diphtheria the corresponding sinuses are always 
involved. In one case of this order he could demonstrate 
diphtheria bacilli in the nose on the one hundred and twenty- 
first day following the beginning of the disease. Those rela- 
tively rare cases in which the disease attacks the skin, the 
genitalia and the stomach hardly enter into consideration 
from the standpoint of the carrier. 



44 DIPHTHERIA 

Virulence of Organisms. — That the bacilli in the throats of 
carriers may be virulent has been abundantly demonstrated 
not only by the animal experiment, -but also by the relative 
frequency with which healthy child carriers fall victims to 
their own organisms. Of the 50 per cent, in which Park 
thus found diphtheria bacilli among those children in whose 
families actual cases of the disease had occurred, 40 per cent, 
later developed corresponding lesions, and of the 8 positive 
cases among the 280 healthy children without a history of 
contact, two developed diphtheria some days after making 
the cultures. From these observations it follows also that 
the existence of the carrier state in a healthy person does 
not necessarily indicate that the individual is immune. 

Non-virulent Strains. — One factor which has complicated 
the elucidation of the true state of affairs in connection with 
the diphtheria carrier problem is the not infrequent occur- 
rence in the throats of perfectly healthy individuals of non- 
virulent diphtheria bacilli, on the one hand, and pseudo- 
diphtheria bacilli, on the other. So far as the above figures 
are concerned these have reference exclusively to the presence 
of virulent organisms, and it is extremely gratifying that 
Park has paid such careful attention to this very point. 
That the organisms harbored by carriers are not necessarily 
virulent, however, is now also known. Goldberger and his 
collaborators thus found that of nineteen carriers only two 
harbored bacilli of high virulence. 32 The non-virulent organ- 
isms differ in no wise from the virulent variety, except in 
the animal experiment, and like the virulent type they pro- 
duce acid in bouillon. Just what their significance is we do 
not know, but manifestly they are not of moment so long 
as their lack of virulence lasts. 

Pseudodiphtheria Bacilli. — So far as the differentiation of 
the pseudodiphtheria bacilli from the true organisms is 
concerned, mistakes are particularly apt to happen if the 
observer is not thoroughly familiar with the normal varia- 
tions in the morphology of both types. Fortunately, it is 
more common that pseudoorganisms are mistaken for the 
true variety, than the opposite. Scheller, 6 whose experience 
is probably typical of that of most investigators, remarks 



MODE OF INFECTION 45 

that with increasing experience he saw pseudobacilli less and 
less frequently, and that in his last series of 1500 examina- 
tions he did not meet with them in a single instance. (See 
below.) 

Mode of Infection. — Considering the extraordinary number 
of carriers, it is, on first consideration, surprising that diph- 
theria is not more prevalent than is actually the case; but 
we must remember that mere contact with a carrier is not 
sufficient to cause the disease. To bring this about the con- 
tact must be intimate, the dose sufficiently large and the 
recipient susceptible. Unless these three conditions exist, 
infection will not occur. As the mucous membrane of the 
upper respiratory tract with its communicating structures 
represents the habitat of the diphtheria bacilli in the carrier, 
as well as in the patient, the organisms are doubtless conveyed 
to others in the salivary "spray" during conversation at 
close range, through the act of sneezing and coughing, through 
the common use of eating and drinking utensils, through 
toys, etc. 

The best protection against infection is, without doubt, 
an intact healthy mucosa. When this barrier is broken, be 
this in consequence of a local inflammatory condition or of 
an injury, the road is open for infection, and under such 
conditions the carrier may fall a victim to his own organ- 
isms, which he may have "carried" for a long period of time 
without injury to himself. But even though the chances of 
infection through the carrier are relatively less than through 
contact with diphtheria patients, the carrier nevertheless rep- 
resents a very real and, at times, most formidable menace to 
the community, for to the manifest danger from the patient 
is added the unknown element of the hidden foe. Against 
the former a defence is possible, for the very reason that the 
danger is manifest, while against the individual who himself 
is usually unaware of his fatal gift, the public is not on guard. 
Unfortunately, we have no actual figures to show just what 
percentage of diphtheria cases are due to carriers, but that 
this percentage may be quite high is evident from the his- 
tories of certain outbreaks which have actually been traced 
to such a source. A few histories of this order are here related ; 



46 DIPHTHERIA 

Examples of Infection by Carriers. — A young married woman 
while living in H. was taken ill with diphtheria. After re- 
covering, she visited her family in the small fishing village 
B. where no diphtheria case had occurred within recent years. 
About a. fortnight later a younger sister, living in the same 
house, developed the disease; then another member of the 
family, then still another, and yet another, until of the entire 
household of about a dozen people, all, with the exception 
of two, had been stricken. From this focus the infection 
then rapidly spread from farm to farm, and from hamlet to 
hamlet, until the total number of cases numbered approxi- 
mately a hundred, with an appalling rate of mortality, in 
the absence of practically any treatment. While no cultures 
were taken there can be no reasonable doubt that the young 
woman in question was a carrier at the time of her return to 
her family. 

A very interesting epidemic of diphtheria occurred at the 
Johns Hopkins Hospital and Medical School in 1911, which 
could be explained only on the basis of the activity of a car- 
rier: 22 On January 25 a pupil nurse was admitted with the 
disease to the isolation ward. On February 3 a patient in 
the male medical ward F was stricken with the malady. 
On February 9 a pupil nurse in charge of the children in ward 
G developed diphtheria, and, on the following day, an em- 
ployee in the baggage room was taken ill. On February 11 
there followed a case in a child in ward G; on February 13, 

2 more cases developed in children in the same ward and on 
February 15 a fourth-year student doing service in the same 
ward was found infected ; 8 cases had thus developed within 
a period of twenty-two days, and 5 of these in the same ward. 
Up to this time the situation was not regarded as out of 
the ordinary. "A more or less systematic examination" of 
patients, nurses and students in ward G was carried out at 
this time, but no additional cases were brought to light. 
On February 20, however, another fourth-year student serv- 
ing in the same ward was found infected, and on February 21 

3 adult patients and 3 nurses, likewise from ward G, also 
another nurse, a roommate of one from the infected ward, as 
well as a nurse in the general operating room who had 



EXAMPLES OF INFECTION BY CARRIERS 47 

handled ward G patients. On February 21 a systematic 
examination of the hospital population was then begun and 
"on the slightest appearance of suspicious symptoms the 
individuals were segregated and cultures taken." On Feb- 
ruary 22, 3 additional cases were discovered, an adult patient, 
a nurse in ward G and a medical intern in another ward. 
On February 23, 7 more cases were found, viz., two more 
children in ward G, three nurses and a member of the second- 
year medical class. On February 24 there followed 11 cases, 
viz., two more nurses, a patient in ward F and eight medical 
students. To date 38 cases had thus developed within a 
month, and it was evident that the disease was rapidly 
spreading from its chief focus in ward G. On February 25 
the medical school was ordered closed. On February 26, 
6 additional cases developed and on February 27, 8 more, 
of which 3 occurred in members of the Faculty or their 
families, making a total of 52 cases. The dispensary was 
then closed, so as to admit no more patients to the hospital, 
w T ith the exception of urgent cases. The medical school 
buildings and the students' dining room were disinfected 
and 300 persons injected with a prophylactic dose of diph- 
theria antitoxin, viz., 200 nurses, 43 students and a small 
proportion of the resident staff, as well as various patients. 
Hereafter the epidemic gradually subsided, although 20 
additional cases occurred between February 27 and March 
22, when the epidemic definitely came to an end. 

It is difficult to account for the development of an epidemic, 
such as the one just described, on any other basis than that 
of the carrier, but unfortunately routine bacteriological 
examinations were not undertaken until the epidemic had 
already made considerable headway, so that the original 
path of infection could no longer be traced. This same 
objection to a lack of an ad oculos demonstration of the 
primary carrier applies to most outbreaks of this order. 
But we must bear in mind that with a type of infection like 
diphtheria, in which transmission occurs not through a food 
or water route, as in typhoid fever, but through the air, the 
tracing of the original carrier must of necessity be very 
difficult, though the discovery of the secondary carriers 



48 DIPHTHERIA 

should be a simple matter if routine cultures are made as 
soon as the first case of the disease appears. Mere throat 
inspection is manifestly not sufficient. 

The direct connection between a carrier and an outbreak 
of the disease has, however, been satisfactorily demonstrated 
in a number of other cases. Hellstroem 23 thus relates the 
following instance: Between December 12, 1894, and Feb- 
ruary, 1895, 25 members of a certain regiment stationed at 
Stockholm were taken ill with diphtheria. As it was thought 
that the outbreak was possibly due to some latent, abortive 
cases or to carriers, Hellstroem made cultures from 15 mem- 
bers of the same regiment, whose throats appeared reddened, 
but who showed no signs of the disease. In 3 of these diph- 
theria bacilli were found. At this time a servant girl was 
brought to the hospital for contagious diseases, suffering 
from a severe case of diphtheria. Regarding the origin of 
her infection nothing could at first be learned; no diphtheria 
cases had occurred at her place of service, nor among her 
relatives or friends. It was found, however, that she was 
engaged to a sergeant of the regiment in question, and on 
examination diphtheria bacilli in abundance could be cul- 
tured from the man's throat, in spite of the fact that physical 
examination revealed no evidence of disease. Thereupon 
the entire regiment was cultured and diphtheria bacilli dis- 
covered in 19.21 per cent, of the men, in the absence of any 
exudation. All carriers were now isolated and the quaran- 
tine suspended only after the bacilli had disappeared. Three 
to four weeks following the establishment of quarantine, a 
young girl was admitted to the hospital suffering from diph- 
theria. It was learned that she was the daughter of one of the 
isolated men, and that the latter had visited his home con- 
trary to orders. Hereafter the carriers were all transferred 
to the hospital until they became bacillus-free, after which 
no more cases developed in the regiment. 

Another instructive example of carrier activity has been 
recorded by Fibiger: 10 In this instance an outbreak of 8 
cases had occurred in a certain school. Fibiger examined 
134 individuals who had been in direct or indirect contact 
with these cases and discovered bacilli in 8. Whereas imme- 



RECOGNITION OF DIPHTHERIA CARRIERS 49 

diate isolation of the patients, besides a general and repeated 
disinfection had not arrested the outbreak, this stopped as 
soon as the carriers had been quarantined and thereafter not 
a single case developed within eighteen months. 

Recognition of Diphtheria Carriers. — The recognition of the 
diphtheria carrier is possible only on the basis of a bacterio- 
logical examination of the throat and nose, and it is well to 
bear in mind that the presence or absence of any redness of 
the throat is of little moment either as evidence pro or contra. 
Unless this be remembered much valuable time will be lost 
in combating an outbreak of the disease. When a case of 
diphtheria develops in a private household every member of 
that household should be promptly cultured. When a case 
develops in a school or an institution, or a factory; in short, 
within a local community, cultures should be taken of every 
individual with whom the patient could possibly have come 
into contact. If any mistake should be made it should be in 
the direction of too extensive an investigation rather than the 
reverse. Then and only then is there a reasonable chance 
of preventing the malady from spreading. Where this is not 
done a more or less extensive epidemic will be the almost 
inevitable consequence. It is for this reason that the occur- 
rence of a case of diphtheria in a country district is so much 
more serious than in a city. In the country a bacteriological 
supervision is practically out of the question, and in a very 
short time a vicious circle between carriers and patients 
becomes established, which only too often is not broken 
until there is no further susceptible human material available 
for the propagation of the disease ., While an examination of 
the throat and nose is thus a sine qua non, it is well to remem- 
ber the frequency with which a median otitis develops in 
connection with diphtheria, and to include an examination 
of any ear discharge in the general investigation. 

The standard culture medium is Loeffler's blood serum. 
Tubes or plates of this should be streaked with sterile swabs 
on which some of the secretion from the pharyngo-tonsillar 
region, on the one hand, and the posterior nares, on the other, 
has been collected. When swabbing the throat special pains 
should be taken, if at all possible, to obtain secretion from the 
4 



50 DIPHTHERIA 

tonsillar crypts (particularly the anterior one) , as it is here 
that the organisms are most apt to persist in carriers. To 
this end it is advisable to use small swabs rather than large 
ones and to penetrate into the crypts as deeply as possible. 

In our larger cities which can boast of a bacteriological 
laboratory in connection with the health department, suit- 
able outfits for cultural purposes are readily obtainable and 
sanitary inspectors are available for work which the general 
physician will not or cannot undertake. In country districts, 
however, the community practically stands defenseless before 
this most formidable disease, and it is urgently necessary 
that steps be taken by our legislative bodies to furnish 
adequate protection in this direction through the establish- 
ment of rural laboratory stations provided with an adequate 
and properly trained personnel. 

While it is exceptionally possible, in carriers, to find diph- 
theria bacilli in the smear made directly from the swab, no 
reliance should be placed upon such technic. Culture should 
be resorted to in every case. A positive result may already 
be reached at the expiration of six to eight hours' incubation, 
but it is wiser to wait a longer time, as some of the charac- 
teristic features of the organism frequently only develop 
after an incubation extending over eleven to thirteen hours. 
At the expiration of this time smears are then prepared and 
stained with a suitable mixture such as that suggested by 
Neisser, particularly one made up according to the following 
formula. This calls for three solutions: The first contains 1 
gram of methylene blue dissolved in 20 c.c. of alcohol, to which 
50 c.c. of glacial acetic acid and distilled water are added to the 
1000 c.c. mark. The second is made by dissolving 1 gram of 
crystal violet (Hochst) in 10 c.c. of alcohol and diluting with 
distilled water to 300 c.c. The third solution is prepared by 
dissolving 1 gram of chrysoidin in 300 c.c. of hot distilled 
water and filtering. The smears are stained with a mixture 
of two parts of number one and one of number two for ten 
to fifteen seconds, after which they are washed in water, and 
counterstained for an equal length of time with number 
three. This mixture brings out in a perfect manner not only 
the polar bodies, but the morphology of the bacilli as well, 



RECOGNITION OF DIPHTHERIA CARRIERS 51 

and for purposes of diagnosis it is essential that both be shown, 
and above all, that the observer be thoroughly familiar with 
the latter, more particularly. If the duration of the incuba- 
tion be as indicated this method alone is perfectly sufficient 
for the diagnosis. Loeffler's solution need then not be 
employed. If, however, the cultures are to be examined after 
five or six hours, already the latter will be found of advantage. 
With the use of Xeisser's solution the differentiation of the 
true from the so-called pseudodiphtheria bacilli or similar 
organisms will cause the experienced worker no difficulty, and 
it may be well to emphasize that the pseudoorganisms are 
after all rarely met with and show no granules, if the above 
technic is employed. As Scheller remarks in commenting 
on this point, he saw fewer and fewer organisms which he 
diagnosed as pseudobacilli as his experience grew, and in his 
last series of 1500 examinations he did not encounter them 
even once. When in doubt it is best to transplant the sus- 
picious colonies, and it will then be found that the second 
generation will show the typical structure, if they are indeed 
true diphtheria bacilli. In conclusion it is the better and safer 
course to call doubtful looking organisms diphtheria bacilli 
than to view them as harmless pseudobacilli. 

Virulence Tests. — Whether the organisms that have been 
diagnosed as diphtheria bacilli on cultural and morphological 
grounds are virulent or not is another question which cannot 
be decided without resorting to the animal experiment. For 
practical purposes it will be best to regard all such organisms 
as virulent, and to act upon this basis, unless there be special 
reasons to the contrary. If the animal test is to be made it is 
advisable to follow the advice of Behring, Escherich, Koplik 
and others, viz., to use young guinea-pigs only — weighing from 
350 to 450 grams. These are injected subcutaneously with 
0.25 to 0.5 per cent., and in special cases even with 1 per 
cent, of their body weight of a forty-eight-hour-old culture 
in bouillon. If the organisms are virulent the animal may 
show evidence of serious illness after six to eight hours, and 
death usually occurs within thirty-six to seventy-two hours. 
Especially characteristic at autopsy is a marked congestion 
of both suprarenals. 



52 DIPHTHERIA 

To economize animal material the method of Zingher and 
Soletsky 37 may also be employed. To this end a colony is 
fished, smeared over a tube of blood serum, and this incu- 
bated for twenty-four hours, when the growth is washed off 
with sterile saline, a fairly dense emulsion being prepared. 
Of this 0.1 to 0.2 c.c. is injected intracutaneously into a 
guinea-pig. If the organism was virulent an area of redness 
and induration develops in from twenty-four to forty-eight 
hours, which usually proceeds to necrosis. 

The Management of the Diphtheria Carrier. — Quarantine. — 
The sine qua non in connection with any measures aiming at 
the eradication of diphtheria is, of course, the isolation of 
the patient and of those who have to do with his care until 
as least two consecutive bacteriological examinations with an 
interval of twenty-four hours of both throat and nose have 
shown that they are free from the corresponding bacilli. So 
long as no adequate provision exists in our cities for the com- 
pulsory removal of diphtheria patients of the humbler walks 
of life to suitable hospitals, so long will diphtheria remain with 
us and so long as physicians disregard the law which calls for 
the notification of the department of health of every case 
of diphtheria, so long will the health and lives of others be 
menaced. Much headway has been made, to be sure, in the 
attempt to eradicate the disease from our midst, and fairly 
satisfactory laws and regulations to this end have been 
enacted in many of our States and cities. (See Appendix.) 
That these regulations, however, are in part insufficient, and 
in part insufficiently observed is evidenced by the fact that 
diphtheria even in our large cities is yet a very common 
malady ; and were it not for the fact that we have learned to 
control its severity by the timely use of antitoxin, it would 
still rank high among our most formidable diseases. 

We have seen that while a large percentage of diphtheria 
patients become carriers during their convalescence, the dura- 
tion of the carrier stage is relatively short, so that no great 
hardship will result from the necessary isolation; and what 
is true of the diphtheria convalescent is true of the entourage 
of the patient in which the carrier condition may have devel- 
oped. Quarantine for both is absolutely necessary and should 



MANAGEMENT OF THE DIPHTHERIA CARRIER 53 

not be lifted until at least two successive bacteriological ex- 
aminations of both throat and nose, separated by an interval 
of twenty-four hours, have given a negative result. 

Use of Masks. — Particularly important as a preventive 
method both in reference to the direct dissemination of the 
disease by patients as well as the production of carriers, is 
the use of gauze masks, 35 both on the part of the patient 
himself and his attendants. This cannot be insisted upon 
too strongly. Its value has been thoroughly established in 
the base hospitals connected with our military camps, and 
it is high time that the health authorities and the medical 
profession of civil communities also should recognize its 
importance and insist upon its use in the management not 
only of diphtheria cases, but of all maladies which are dis- 
seminated through the secretions of the respiratory tract. 

Medical Treatment of Carriers. — A good deal has been writ- 
ten regarding the question whether or not it is possible to 
shorten the carrier stage, and especially whether or not it is 
possible to cure the condition in the chronic cases, by medic- 
inal or other methods. A priori one should expect this to 
be possible, bearing in mind that the organism is not a very 
hardy one, and most observers are agreed that the local 
application of various disinfectants is of distinct benefit. 
Park 2 thus pointed out that in one-half to two-thirds of the 
cases thorough irrigation of the throat and nose with a 
1:4000 bichloride of mercury solution, at intervals of a few 
hours, will lead to the disappearance of the diphtheria bacilli 
within three or four days following the disappearance of the 
membrane. But in the remainder they persisted nevertheless. 
Loeffler 12 recommended his well-known mixture, composed of 
36 c.c. of toluol, 60 c.c. of absolute alcohol and 4 c.c. of liquor 
ferri sesquichlorati, to w T hich 10 grams of menthol were added 
to lessen the pain attending the application of the remedy. 
This mixture, as a matter of fact, is very efficacious when it 
can be brought into intimate contact with the organisms, but 
unfortunately this is possible only to a limited extent. The 
same is true of the local application of many other substances, 
such as hydrochloric acid and various chlorides, as zinc 
chloride, the double chloride of sodium and gold, the tri- 



54 DIPHTHERIA 

chloride of iodin; further of nitrate of silver, collargol, 
lactic acid, potassium chlorate, sulphurous acid, hydrogen 
peroxide, etc. Wassermann 24 recommended the local ap- 
plication of a bactericidal serum, prepared by injecting 
animals with the dead bodies of bacilli, but this also does 
not appear to lead to the desired end. Emmerich 25 recom- 
mended a ferment obtained from the Bacillus pyocyaneus, 
which in the test-tube brings about the digestion of the 
bacilli, and which is said to be of great benefit in the treat- 
ment of pharyngeal diphtheria, with extension into the larynx 
and nose; but there is thus far no satisfactory evidence that 
the carrier stage can be satisfactorily influenced in this man- 
ner. More recently it has been suggested that the diphtheria 
bacilli can be crowded out by the introduction of pure cul- 
tures of the Staphylococcus aureus. This idea is based upon 
the observation of Schitz 26 that the bacilli disappeared in 
some cases following a supervening infection with staphylo- 
cocci. While several investigators 27 have reported encourag- 
ing results, others did not find that the period of quarantine 
was appreciably lessened by this method. 28 

Inhalation of various disinfectants has also been suggested, 
but so far as the results go that have been recorded in the liter- 
ature, no very satisfactory conclusions can be drawn. In the 
French army the following procedure was in vogue in 1910: A 
mixture composed of 12 grams of iodin, 2 grams of guaiacol, 25 
grams of thymol and 6 grams of potassium iodide, dissolved 
in 200 c.c. of 60 per cent, alcohol, was poured into a porcelain 
dish, and this floated on a basin of boiling water. The car- 
rier was then instructed to inhale the fumes from this mix- 
ture at five sittings of two or three minutes' duration in the 
course of twenty-four hours. As no report has appeared 
concerning the efficacy of this treatment we may assume 
that it was not very successful. 

Petruschky 29 and others have used a vaccine made of dead 
diphtheria bacilli, and thought they obtained some results 
of value, but this method also has not survived. 

In times of epidemics diphtheria antitoxin is, of course, 
extensively used for prophylactic purposes and rightly so, 
and while it is probably the only efficacious method in exist- 



MANAGEMENT OF THE DIPHTHERIA CARRIER 55 

ence, to stamp out the disease in situ, especially when coupled 
with widespread quarantine, the use of the antitoxin is 
absolutely without effect upon the persistence of the bacilli 
and the carrier state. On this point the verdict is quite 
unanimous. Prip 3 in particular mentions that the use of 
antitoxin, given for curative purposes, has not the slightest 
effect upon the continued existence of the bacilli in the fauces. 
That this should be so really stands to reason, if we remember 
that the serum in question is purely an antitoxic serum. 

The reason why all these various methods of treatment do 
not lead to the desired end is unquestionably because the 
principal foci where the organism vegetates cannot be reached 
in such a manner. In the past we have thought of the bacilli 
as existing upon the mucous surfaces of the throat and nose, 
but evidence is rapidly accumulating that the organisms 
which are here present have reached these surfaces only more 
or less accidentally, and that the actual foci of development 
are located below the surface in various nooks and corners, 
where local applications could scarcely reach them. Here, no 
doubt, in the majority of cases they gradually fall prey to 
the normal and natural defenses of the body, or die in con- 
sequence of lack of suitable nourishment, or they may be 
crowded out by other bacteria. But, as we have seen, they 
do persist in some, and in the management of these cases the 
best course to pursue, aside from the education of the victim, 
is to attempt to find their hiding place and to eradicate this 
as thoroughly as possible. Whether or not this can be accom- 
plished will, of course, depend upon the individual case, but 
there can be no doubt that the best chances of ridding the 
individual of his fatal possession lie in this direction. As 
yet comparatively little work has been done from this point 
of view, but the little that has been accomplished is dis- 
tinctly encouraging. Albert 30 thus relates that in the course 
of an outbreak of the disease in the University Hospital of 
Iowa City, a number of carriers, who had been isolated, 
attempted to bring about their release by using a disinfectant 
gargle within fifteen minutes of the time that cultures were 
to be taken. In five of the eight individuals the cultures from 
the surface were then actually negative, whereas all but one 



56 DIPHTHERIA 

culture from the crypts of the tonsils were positive. The 
writer then reports that he succeeded in ridding all of the 
fourteen cases of their bacilli by treatment of the crypts of 
the tonsils with a 5 to 10 per cent, solution of nitrate of 
silver, which was applied by means of a thin, flexible appli- 
cator, and he adds that a number of physicians to whom he 
recommended this treatment had informed him that this 
method yielded better results than any other that had been 
tried. In his own series of cases the organisms disappeared 
within three days. Unfortunately the writer does not state 
whether any or all of the cases were temporary or chronic 
carriers, but even if they were temporary carriers only, the 
results achieved in so short a time are certainly very encour- 
aging. 

Kretschmer 31 reports that he was able to free from the 
carrier condition thirteen patients in whom the more simple 
methods had failed, by squeezing the tonsils and forcing the 
plugs of detritus out of the crypts. 

Surgical Treatment. — While these methods may be appli- 
cable in the case of temporary carriers, and mark an advance 
in our methods of treatment, in so far as they attempt to 
eradicate the niduses of bacillary development, rather than 
to treat the organisms that happen to be located on the sur- 
face of the epithelial lining of the fauces, they will scarcely 
suffice to rid some chronic carriers at any rate of their organ- 
isms. Dr. Hogan, who had charge of the Sydenham Hospital 
for contagious diseases of Baltimore, has thus related to me 
the case of a young woman in whom all applications, even 
injections of nitrate of silver into the substance of the tonsils, 
were in vain. 

The individual was a chronic carrier who had been respon- 
sible for an outbreak of diphtheria in a local reformatory and 
had been kept in quarantine, under treatment most of the 
time for one hundred and thirty-six days. Finally it was 
decided to remove her tonsils and thirty days later she could 
be discharged, after repeated cultures had shown that her 
carrier condition had come to an end. A similarly satisfac- 
tory result was obtained in another case in whom the carrier 
state had followed an attack of the. disease. It is noteworthy 



MANAGEMENT OF THE DIPHTHERIA CARRIER 57 

in connection with the first case that the tonsillectomy was 
performed without a preceding administration of antitoxin 
and that the wound healed without complications. Similar 
results have been obtained by others. 

McCord, Friedlander and Walker 34 report that at Camp 
Sherman tonsillectomy was carried out in a number of cases 
with a quick termination of the carrier condition in all. Even 
if tonsillectomy may not be necessary in all cases, it is sug- 
gested to refer every carrier to the throat specialist never- 
theless for treatment of any ulcers or crypts in the tonsillar 
or adenoid tissue. The same observers speak favorably of 
the use of an 0.25 per cent, aqueous solution of chloramin-T 
(chlorazene) as a gargle (three or four times daily), followed 
by an oily spray of dichloramin-T, of 2 per cent, strength. 
They found that by systematizing the treatment of the car- 
riers along these lines, it was possible to return them to duty 
after an average of only twenty-three days in the hospital, 
whereas before that time this was fifty-five days for diph- 
theria cases that had become convalescent carriers. 

Keefer, Friedberg and Aronson 36 have reported similar 
successes from Camp Doniphan. They found, that of 294 
carriers in whom tonsillectomy was performed 94, or 32 per 
cent, only, gave negative cultures immediately after the 
operation; 136, i. e., 46.4 per cent., became negative by the 
end of the first week; 38, or 12.9 per cent., by the end of 
the second week; 11, or 3.7 per cent., by the end of the third 
week; 14, or 4.7 per cent., by the end of from four to eight 
weeks, while a single case proved refractory altogether. 

Such results show that the earlier problem so far as diph- 
theria is concerned is not only theoretically, but under mili- 
tary conditions at least practically, also capable of a satis- 
factory solution, in a large number of cases, but I fear that in 
civil life we are as yet very far from that goal. 

In those cases in which the tonsils can be excluded as the 
habitat of the bacilli, the discovery of their hiding place may, 
of course, be attended with great difficulties, and their eradi- 
cation be impossible. As a matter of fact, military surgeons 
have found that the nasal carriers are the most difficult to 
treat, and that in many of those showing atrophic rhinitis and 



58 DIPHTHERIA 

infected sinuses a cure can hardly be expected. A great ideal 
of further work thus still remains to be done, but I believe 
that as soon as the idea is once definitely abandoned, that in 
the carrier the organisms "grow on the surface," and it is 
realized that it is essential to search for their focus or foci 
of development, real headway in the cure of these people will 
be made. In the meantime, of course, we must handle the 
carrier problem as best we may. Most important naturally, 
as I have already pointed out, is the determination whether 
or not individuals who have recently passed through the dis- 
ease, as well as those with whom they have been in contact, are 
carriers. This is purely a bacteriological problem and is to 
be solved by bacteriological methods (see above). When 
once the diagnosis has been made, quarantine and local 
treatment are next in order, coupled with adequate instruc- 
tion of the individual regarding the danger which he repre- 
sents through contact with other people. If the persistence 
of the organisms should unfortunately stamp the individual 
as a chronic carrier, the quarantine must, of course, be lifted, 
as it is manifestly out of the question to hold the person 
indefinitely. Much will henceforth depend upon his own good 
sense and good will, and if both be good he may prove of 
but slight danger to his entourage. But in any event it will 
be essential to keep such a person under supervision. He 
should be compelled to report from time to time to the proper 
authorities, and his whereabouts should at all times be known, 
so that in case of an outbreak of the disease it can be deter- 
mined whether he could possibly have been the causative 
agent. So long as this does not occur he may remain at 
liberty. If, however, it can be shown that through his own 
carelessness he has brought about an outbreak of the malady, 
it would seem proper to confine him under surroundings 
where he cannot do any harm. Like carriers of other disease 
germs, he should under no circumstances be permitted to 
engage in the handling or preparation of foodstuffs, excepting 
in his own family and then only, if it is absolutely imperative. 
As the susceptibility to diphtheria is particularly great in 
children it would also suggest itself that the carrier be 
excluded from contact with children as far as possible. This 



BIBLIOGRAPHY 59 

would apply particularly to school teachers and to nurses 
and attendants in hospitals and similar institutions. 

BIBLIOGRAPHY. 

1. Escherich: Centralbl. f. Bakt., 1819, vol. vii. 

2. Biggs: British Med. Jour., 1894, vol. ii, p. 360. 

3. Prip: Ztschr. f. Hyg., 1901, vol. xxxvi, p. 283. 

4. Tiaden: Deutsch. Arch. f. klin. Med., 1906, vol. lxxxix, p. 292. 

5. Glucksmann: Ztschr. f. Heilk.', 1897, vol. xvi, p. 417. 

6. Scheller, R. : Beitrage z. Diagnose u. Epidemiologie d. Diphtheritis, 
Centralbl. f. Bakt., 1906, vol. xl, i t p. 1. 

7. Neisser, M., and Heymann: Klin. Jahrb., 1899, vol. vii, p. 259, and 
Berlin klin. Wchnschr., 1904, p. 283. 

8. Neisser, E., and Gabriel: Deutsch. med. Wchnschr., 1902, No. 40. 

9. Hewlett and Nolan: British Med. Jour., 1897. 

10. Fibiger: Centralbl. f. Bakt., 1897, vol. xxiii, p. 564. 

11. Le Gendre and Pochon: Semaine medicale, 1895. 

12. Loeffler, F.: Mittheil. aus d. kais. Gesundheitsamt, 1884, vol. ii; 
Deutsch. med. Wchnschr., 1890, Nos. 5 and 6; ibid., 1891, No. 10; ibid., 
1894, No. 42; Centralbl. f. Bakt., 1894, vol. xvi, p. 955. 

13. Vogt: Norsk. Magaz. f. Laegevidensk., 1895, vol. x, p. 184. 

14. Johannesen: Diftericus Forekomst i Norge, Christiania, 1888. 

15. Muller, E.: Jahrb. f. Kinderheilk., 1896, vol. xliii, p. 54. 

16. Stenmeyer: Dissert. Utrecht, ref. Baumgartens Jahresber., 1898, 
p. 316. 

17. Kober: Ztschr. f. Hyg., 1899, vol. xxxi, p. 433. 

18. Sommerfeld, P.: Zur Epidemiologie d. Diphtherie, Arch. f. Kinder- 
heilk., 1911, vol. xlvii. 

19. Beck: Ztschr. f. Hyg., 1890, col. 8. 

20. Fibiger: Berl. klin. Wchnschr., 1897, Nos. 35-38. 

21. Wolff: Ztschr. f. Hyg., Die Nebenhohlen d. Nase b. Diphtherie, 
Masern and Scharlach, vol. xix, p. 225. 

22. Ford, W. W.: The Recent Epidemic of Diphtheria in the Johns 
Hopkins Hospital and Medical School, Johns Hopkins Hosp. Bull., 1911, 
vol. xxxiii, p. 357. 

23. Hellstroem, T.: Festschr. f. Med., Dr. Warfringe, Stockholm, 1896, 
and Hygei, 1890. 

24. Wassermann: Deutsch. med. Wchnschr., 1902, No. 44. 

25. Emmerich: Munchen. med. Wchnschr., 1907, pp. 2217 and 2285. 

26. Schitz, A.: Ugesk. f. Laeger, 1910, vol. lxxi, No. 49. 

27. Catlin, S. R., Scott, L. O., and Day, D. W.: Successful Use of the 
Staphylococcus Spray on Diphtheria Carriers, Jour. Am. Med. Assn., 1911, 
vol. lvii, p. 1452. Lorenz, W. F., and Ravenel, M. P.: The Treatment of 
Bacillus Carriers by Overriding with Staphylococcus Aureus, Jour. Am. 
Med. Assn., 1912, vol. lix, p. 690. 

28. Womer, W. A.: Results of Staphylococcus Spray Treatment in 
Forty-two Cases of Diphtheria Carriers, Jour. Am. Med. Assn., 1913, vol. 
lxi, p. 2293. 

29. Petruschky: Arb. aus. d. path. Inst. z. Tubingen, 1908, vol. vi, Pt. 2, 
p. 331. 



60 DIPHTHERIA 

30. Albert, H.: The Treatment of Diphtheria Carriers, Jour. Am. Med. 
Assn., 1913, vol. lxi, p. 1027. 

31. Kretschmer, M.: Zur Bekampung d. Bazillenpersistenz bei Diph- 
theriekonvalescenten, Med. Klin., 1911, vol. vii, No. 3. 

32. Goldberger, J., Williams, C. L., and Hachtel, F. W.: Bull. 101, 
Hyg. Lab., U. S. Public Health Service, 1915. 

33. Labit: Arch. d. med. et d. pharm. mil., 1917, vol. lxvii, p. 779. 

34. McCord, Friedlander and Walker: Diphtheria and Diphtheria 
Carriers in Army Camps, Jour. Am. Med. Assn., 1918, vol. lxxi, p. 275. 

35. Weaver, G. H.: The Value of the Face Mask, etc., in the Prevention 
of Diphtheria, Meningitis, Pneumonia, etc., ibid., 1918, vol. lxx, p. 76. 
See also: Hallen, D. A. and Colwell, R. C: The Protective Qualities of the 
Gauze Mask, ibid, vol. lxxi, p. 1213, and Doust, B. C. and Lyon, A. B., 
Face Masks in Infections of the Respiratory Tract, ibid, p. 1216 

36. Keefer, F. R., Friedberg, S. A. and Aronson, J. D.: A Study of Diph- 
theria Carriers in a Military Camp., ibid., 1918, vol. lxxi, p. 1206. 

37. Zingher, A., and Soletsky, D.: An Economic Intracutaneous Method 
of Testing the Virulence of Diphtheria Bacilli, Jour. Infect. Dis., 1915, vol. 
vii, p. 456. 



PLAGUE. 

While there is no evidence to show that the bubonic type 
of plague is ever transmitted from man to man, 1 the conta- 
giousness of pneumonic plague is well known, and the question 
naturally suggests itself whether carriers may not play a 
role in the dissemination of this type of the malady. Unfor- 
tunately we are not yet in a position to speak definitely on 
this point, but so far as the available evidence goes, it would 
seem that pneumonic plague may indeed be transmitted in 
this manner. 

Active Carriers. — Gotschlich 2 has thus reported two cases 
of secondary and one case of primary plague pneumonia, in 
which virulent plague bacilli could be demonstrated in the 
sputum several weeks after convalescence. In the first case 
the pneumonia developed on the fifth day of the disease. 
The patient left his bed for the first time on the thirty-fourth 
day, and was continuously up and about after the sixtieth 
day. But notwithstanding, bacilli were demonstrable in the 
bit of sputum which the man could furnish, as late as the 
seventy-sixth day. In the second case plague bacilli were 
demonstrated in the sputum by animal experiment twenty 
days following a return to normal temperature, and six days 
after the patient had definitely left his bed. In the third 
case, which was a primary plague pneumonia, the patient 
was continuously up and about after the twenty-second day, 
and although his sputum scarcely differed from ordinary 
saliva in appearance, it nevertheless contained virulent 
bacilli as late as the forty-first day. These findings, of course, 
prove beyond a doubt that convalescents from plague pneu- 
monia may be carriers for a time sufficiently long to infect 
others, providing, of course, that the retention by the organ- 
isms of their virulence for the experimental animal implies 
that human beings also would be subject to infection. 



62 PLAGUE 

Since Gotschlich's initial observations similar findings have 
been reported by other investigators. Vagedes 3 thus mentions 
a case in which the bacilli persisted in the lung for two months, 
though it must be mentioned that the patient was continu- 
ously febrile. Voges 4 cites an instance in which the organisms 
were demonstrable in large numbers four weeks after the 
beginning of the disease, and when the patient had been 
convalescent for some time. 

Me tin, 5 on the other hand, was unable to demonstrate 
plague bacilli in the sputum of plague pneumonia convales- 
cents after the ninth afebrile day, and he relates that during 
convalescence their virulence seemed to be diminished. He 
nevertheless regards such cases as exceedingly important from 
an epidemiological standpoint. 

Schottelius, 6 further, has pointed out that in addition to 
the pneumonic form of the disease, there exists also a bron- 
chitic type running a course of greater or lesser intensity, in 
connection with which he was able to demonstrate the pres- 
ence of plague bacilli in the sputum in large numbers, and he 
rightly regards the lighter forms of this type as particularly 
dangerous, as their true nature would not be suspected with- 
out a bacteriological examination. 

Passive Carriers. — While there can be no doubt that con- 
valescents from plague pneumonia may harbor and eliminate 
the corresponding organisms in their sputum for a time 
sufficiently long as to warrant their classification as active 
carriers, there is thus far no evidence to show that the disease 
may also be transmitted through the intervention of passive 
carriers. Strong 9 and his collaborators state that there is no 
definite bacteriological evidence that healthy carriers of the 
disease with plague bacilli in their sputa existed during the 
Manchurian epidemic of pneumonia plague of 1910-11, but 
he mentions that they had occasion t® examine only two 
persons who were suspected of being carriers of this order. 

There are a few observations which go to show that an 
individual may harbor the organisms in his sputum for sev- 
eral days preceding the outbreak of the malady in his own 
person, 7 8 and it goes without saying that such individuals 
may be dangerous to others. But they cannot be viewed as 



MODE OF INFECTION 63 

proper carriers in the sense in which we usually employ the 
term, unless it could be demonstrated that such persons 
harbored the organisms for a period that extended beyond 
that of the incubation of the malady. 

Mode of Infection. — From the standpoint of prophylaxis it 
is, of course, clear that any person who eliminates plague 
bacilli in his sputum should be treated exactly as a plague 
pneumonic, and that no individual who has suffered from this 
type of the malady should be released from quarantine until 
repeated bacteriological examinations have shown that he 
is not a carrier. It has been argued inasmuch as plague 
pneumonia ordinarily occurs in only about 2.5 per cent, of 
all bubonic plague cases, that individuals suffering from this 
form of the disease are a negligible factor in the dissemina- 
tion of the malady; that an epidemic of human plague always 
presupposes the existence of acute rat plague, and the trans- 
ference of bacilli from infected rats to human beings through 
the agency of the rat flea. On the other hand, the belief has 
been expressed that a rat epidemic cannot be initiated through 
fleas that have been infected by biting human beings, the 
principal argument against such a possibility being the fact 
that the amount of blood which the insect could take up from 
the human being would not contain a sufficient number of 
bacilli to bring about the infection of a rat through natural 
methods.* However this may be, it must be admitted that 
plague may at times show a much more marked tendency to 
assume the pneumonic form than is ordinarily the case, so 
much so, in fact, that one can speak of actual epidemics of 
plague pneumonia (e. g., the Manchurian epidemic of 1910- 
11), and by such patients the plague bacilli are disseminated 
in huge numbers. 9 This being the case it would suggest 
itself that rats might very well receive a surface infection 
of their skin from such a source, sufficient in extent to 
lead to an outbreak of the disease, if such animals were 
then bitten by a flea. We must remember that the con- 

* Strong aDd his collaborators found, on the other hand, in plague pneu- 
monia that in many instances the bacteria are present in the blood in very 
large numbers, so that a diagnosis can often be made from a single micro- 
scopic examination. 



64 PLAGUE 

elusion has been reached that the ordinary rat epizootic 
is initiated through the infection of an individual rat 
in consequence of a flea's biting through an area of skin 
that has previously been soiled by the discharges of an 
infected flea, and if this be so it would certainly suggest 
itself that the same result would follow if the surface contami- 
nation of the rat's skin had occurred through soiling with the 
sputum of a human plague pneumonic, either directly or 
indirectly, in the form of dust. Should future investigations 
show that this is possible it would also follow that a conva- 
lescent from plague pneumonia might initiate a rat epizootic 
and thus indirectly give rise to an epidemic of the ordinary 
type of plague. 

Recognition of Plague Carriers. — Animal Experiment. — The 
recognition of plague carriers is effected most readily by 
inoculating rats subcutaneously at the root of the tail with 
a small quantity of the individual's sputum, or the discharge 
from broken down glands, suitably emulsified with a little 
saline. If plague bacilli be present death invariably results 
within ten days, the animals presenting characteristic lesions 
which are readily recognized with the naked eye, viz.; 
engorgement of the subcutaneous vessels, pink coloration of 
the muscles, and the presence of bubos which are surrounded 
by an area of marked injection, with occasionally hemor- 
rhagic infiltration. The gland itself is firm, but usually 
caseous, and at times hemorrhagic. The liver appears 
stippled and as though dusted with pepper. Pleural effusion, 
when present, is especially characteristic. The spleen is 
much enlarged, friable and often speckled like the liver. 

Bacteriological Examination. — Cultures should be prepared 
from the bubo, the heart blood, the spleen and the liver, 
for which purpose ordinary meat infusion broth, layered with 
a little sterile oil or butter, and meat infusion agar — the 
latter containing 3 per cent, of sodium chloride, will be found 
best. The reaction should be. neutral or slightly alkaline. 
The specimens should be incubated at a temperature of from 
25° to 35° C; above 38° growth is much delayed. During 
its growth in bouillon, which takes place slowly, the organism 
forms flakes or flocculi which rapidly sink to the bottom 
of the tube, leaving the supernatant fluid clear. Stalactite or 



MANAGEMENT OF THE CARRIER 65 

stalagmite formations may also be seen starting from the 
walls of the tube or from the suspended droplets of oil or 
butter. On agar after twenty-four to forty-eight hours, the 
colonies are small, delicate, transparent, dew-drop like. 
x\fter forty-eight to seventy hours they have become larger, 
raised and less transparent. Mucin production is variable. 

In stained preparations the characteristic appearance of 
the organism is that of a short, more or less ovoid bacillus, 
swollen in the center and rounded at the ends, whose polar 
regions are readily stained with dilute carbol fuchsin or 
borax methylene blue* (one-half minute), while the interpolar 
area remains colorless. They appear singly, in pairs and 
sometimes in short chains. To bring this out the smears 
should be fixed by absolute alcohol, and not by heat. 

On agar, involution forms are obtained among which there 
are long, slender, segmented bacilli of vacuolated appearance, 
while others resemble yeast cells, and still others appear club 
shaped. Many of the involution forms stain only very 
imperfectly, and sometimes only a portion of the organism 
takes up the dye. The organism is negative to Gram. In 
hanging drop preparations no true motility is noted. Tested 
against antisera which have been prepared by immunizing 
rabbits with living, avirulent plague bacilli, administered 
intravenously, agglutination is observed in 1 to 80 dilutions 
(using 0.5 per cent, saline as diluent, and for the purpose of 
emulsifying the organisms), when the organism is isolated 
from infected guinea-pigs, while when cultured from human 
lesions, the same result is obtained in dilutions varying 
between 1 to 160 and 1 to 1280, according to the nature of 
the strain. The period of observation should be from two 
to four hours, and controls set up with normal rabbit serum. 

Management of the Carrier. — Quarantine. — While the Indian 
Plague Commission of 1908 concluded "that there is no evi- 
dence that man harbors the bacilli after he has recovered 
from the disease," and while there is apparently no danger 
of man's conveying the malady to non-infected districts, 
excepting through the agency of transported infected rat 
fleas, it would seem advisable nevertheless to quarantine 

* The solution is a 2 per cent, solution of methylene blue in 5 per cent, 
borax water. 
5 



66 PLAGUE 

plague cases until bacteriological examination has proved that 
any discharge from the seat of the malady, at a time when 
the patient is otherwise well enough to leave the hospital, is 
actually free from plague bacilli. It is, of course, well known 
that in the majority of cases no living bacilli can be demon- 
strated in the pus of the bubos, by the time that they break 
through the skin, but that this is not invariably the case 
has also been shown, 10 

So far as the management of plague carriers of the respiratory 
type is concerned, the same regulations should, of course, 
apply to these, as to actual plague pneumonia, and to 
diminish the chances of the production of carriers of this 
order, irrespective of the elimination of danger to the patient's 
entourage, the latter should be capped, gowned and masked, 
and as Strong and his collaborators have suggested, protected 
with goggles. Hospitalization of the patients themselves is, 
of course, absolutely essential and should be carried out 
whenever possible, and as the organisms seem to be able to 
persist outside of the body for a considerable length of time, 
in dust and on fomites of all kinds, the liberal use of disin- 
fectants must be regarded as one of our most important 
methods of defense.* 

BIBLIOGRAPHY. 

1. The Etiology and Epidemiology of Plague: A Summary of the Work 
of the Indian Plague Commission, Calcutta, 1908. 

2. Gotschlich, E.: Ueber wochenlange Fortexistenz lebender virulenter 
Pestbacillen im Sputum geheilter Falle v. Pestpneumonie, Ztschr. f. Hyg. 
und Infektionsk., 1899, vol. xxxii, p. 402. 

3. Vagedes: Arbeit, aus d. Kaiserl. Gesundheitsamt, 1900, vol. xvii. 

4. Voges: Ztschr. f. Hyg. u. Infektionsk., 1902, vol. xxxix. 

5. Metin: Annal. de l'lnst. Pasteur, Quelques experiences sur la peste 
a Ports, 1900, vol. xiv, p. 420. 

6. Schottelius: Hygien. Rundschau, 1901. 

7. Voges (see 4). 

8. Thompson, A.: Report of the Board of Health on Plague in New 
South Wales, 1906 (Sydney, 1907). 

9. Strong, Teague and Barber: Studies on Pneumonic Plague, Philip- 
pine Jour. Sc, 1912, Sect. B, vol. vii. 

10. Report of the Austrian Plague Commission, Vienna, 1898; see also 
Vagedes (3) and Albrecht and Ghon, Ueber d. Beulenpest in Bombay im 
Jahre 1897, K. Akad. d. W 7 iss. (1898), vol. ii. 

* Strong and his collaborators have pointed out that the sputum from pneu- 
monic plague is no longer infectious when thoroughly dried, but that when 
frozen and pulverized, particles of it may be blown about and remain infec- 
tive for long periods of time, or until the sputum is again thawed. 



TYPHOID FEVER. 

The impetus to the splendid series of investigations which 
culminated in the recognition of the important role which car- 
riers play in the dissemination of typhoid fever was given by 
Koch 1 in 1902. Basing his conclusions upon the findings col- 
lected by the Typhoid Commission of Trier, in the course of the 
preceding nine months, he expressed the belief that the propa- 
gation of typhoid fever took place essentially through the 
transference of the corresponding organisms from individual 
to individual, and that while infected drinking water could 
unquestionably produce the disease, infection of the water 
by a typhoid individual must inevitably precede and that 
a non-infected even though bad water in itself can have noth- 
ing to do with the production of the malady. He maintained 
that in the past too much emphasis had been placed upon the 
possibility that certain periodical outbreaks of the disease — 
notably in so-called typhoid houses and typhoid districts — 
might have been due to the activity of typhoid organisms 
which had been lying dormant possibly for years, in soil and 
ground water, and which then through water-courses had 
found their way into the drinking-water supply and thus 
brought about the outbreak. As a matter of fact, the origin 
of many outbreaks, notably those of a local character, 
seemed in those days so completely wrapped in obscurity, 
that the assumption of a possible latent existence of the organ- 
ism, viz., an existence outside of the human body, did not 
appear unwarrantable, even though unsupported by tangible 
evidence. Certain bacteriologists, in fact, expressed the belief 
that the typhoid bacillus might develop directly from the 
colon bacillus through a process of mutation and that some 
of the obscure outbreaks of the malady might be accounted 
for upon this basis. Suffice it to say that the possibility of 
such a transformation has not been demonstrated and need 



68 TYPHOID FEVER 

not be considered, from a practical standpoint until such a 
demonstration has actually been made. 

Koch's dictum, as outlined above, was, however, not only 
based upon the results of epidemiological studies per se, but 
further supported by observations on the part of various 
investigators, to the effect that typhoid bacilli may be found 
in the gall-bladder and abscesses of various organs, many 
years following an attack of typhoid fever, and that they 
may be present in the feces and urine of typhoid convales- 
cents. Isolated observations of this order had been made 
already by Neufeld 2 and others, but in these cases the organ- 
isms ultimately disappeared, as the patients regained their 
full strength. 

Active Carriers. — In the course of the investigations, which 
were made at Trier, referred to above, Frosch 3 encountered 
certain individuals who had passed through an attack of 
typhoid fever, in whom the organisms persisted — in other 
words, individuals in whom a bacteriological recovery did 
not coincide with or even follow clinical recovery. It is to 
be noted that Frosch fully realized the significance of these 
findings, and emphasized their importance at the meeting 
of the directors of the various Typhoid Stations which the 
Prussian Government had established at Koch's solicitations. 
At that time he supported his belief that such individuals 
might play an important role in the dissemination of the 
disease by similar findings which had been noted by 
v. Drigalski 4 and Donitz. 5 The former had an individual 
under observation at the time, who ever since his clinical 
recovery from typhoid fever, four months before, was still 
eliminating typhoid bacilli in the feces.* 

Donitz' s patient was a woman in whom typhoid bacilluria 
still existed nine months after recovery. 

An enormous amount of work then followed which was 
largely carried out at the Research Stations established at 
Trier, Saarbriicken, Idar, Metz, Strassburg and Landau. 
This work is prominently connected with the names of 
Lentz, 6 Drigalski, 7 Frosch, 8 Forster 9 and his collaborators, 

* This person was evidently a permanent carrier, as the elimination was 
still noted one and three quarter years following recovery from the disease, 



ACTIVE CARRIERS 69 

Levy, 10 Blumenthal, 11 Fornet, 12 Kayser, 13 Klinger, 14 Minelli 15 
and many others. 

The immediate results of these investigations thoroughly 
supported the opinion expressed by Koch, that in the dis- 
semination of typhoid fever the typhoid convalescent plays 
a most important part, and fully established the status of 
the typhoid carrier as we understand it today. 

Duration of the Carrier Stage. — It was shown by Drigalski 7 
that typhoid bacilli are eliminated in the feces either con- 
tinuously or periodically by a large number of the patients 
during the active period of the disease, the percentage rang- 
ing from 15.6 during the first five days to 11.5 during the 
fourth week, and that in fully 11 per cent, of the individuals 
this continues into the period of convalescence, viz., the 
eighth to the tenth week; in other words, that in point of 
time clinical recovery precedes bacteriological recovery. In 
the majority of normal cases the latter takes place after 
eight to ten weeks, dating from the beginning of the disease, 
and in those complicated by relapses eight to ten weeks 
following the last relapse. During the stage of convalescence 
the individual may accordingly be viewed as a carrier. This 
type, however, is not to be confounded with those rarer cases 
in which the elimination of bacilli continues beyond the tenth 
week. While it is admitted that bacteriological recovery 
may take place even then, this is exceptional, and in the 
majority of cases the elimination of the organisms in question 
continues practically indefinitely. In the series of 400 typhoid 
cases analyzed by Lentz there were only six in whom the 
ten-week period was exceeded and bacteriological recovery 
still occurred, the time ranging between three and a half 
and nine months. Fifteen out of the total number, i. e., 
3.75 per cent., apparently became permanent carriers. The 
assumptiou that the condition was actually a permanent 
one was based not only upon the findings obtained in con- 
nection with the cases which had developed during the dura- 
tion of the existence of the Commission, but also upon the 
results obtained in connection with the examination of indi- 
viduals whose typhoid attack antedated that period. 

The other observers taking part in the investigation 
obtained similar results. 



70 TYPHOID FEVER 

Passive Carriers. — At the Strassburg Station during the 
period from July 1, 1903, to March 31, 1905, 23 carriers 
were discovered, which Klinger 14 reported in 1906; 11 of these 
gave no history whatsoever of a preceding attack of typhoid 
fever. They were encountered in the coarse of an examina- 
tion of 1700 supposedly healthy individuals, who, however, 
had been in contact with typhoid patients. This would cor- 
respond to a percentage of 0.64. In all of these the appear- 
ance of the typhoid bacilli in the discharges was temporary. 
In 9 of the 11 the organisms were found only once; in the 
tenth case three times in the course of a fortnight, and in the 
eleventh twice in the course of a month. The remainder, 
viz., 12, were true permanent carriers; 8 of these had devel- 
oped the carrier condition while under observation in con- 
nection with an attack of typhoid fever. As the total number 
of typhoids under investigation during that time was 482, 
the percentage of resultant chronic carriers would be 1.7 
as contrasted with 63, i. e., 13.1 per cent., of temporary 
carriers. 

All of the carriers observed by Klinger were fecal carriers, 
though it is to be noted that in eight the organisms were also 
found in the urine — urinary carriers. The writer mentions 
particularly that the number of bacilli in the latter was 
always small and that a bacteriuria such as one frequently 
sees in the course of the malady and during convalescence, 
with millions of organisms to the cubic centimeter, was 
never observed. Carriers of this order have been described 
by practically all investigators of the problem. One of the 
earliest observations of the kind was made in 1900 in our 
own country, by Brown, 18 who reported the case of a woman 
in whom a cystitis developed on the ninth day following an 
abdominal operation, and in whom it was thought that the 
typhoid bacillus was accidentally introduced by catheter. 
It is to be noted, however, that the woman had had typhoid 
fever thirty-five years previously, and in view of our present 
knowledge it is more likely that she was a carrier during all 
this time than that she was infected with a catheter — at one 
of the most up-to-date institutions of our country. Young 19 
described another case of this type in 1901. In this patient 



INTERMITTENT ELIMINATION OF THE ORGANISMS 71 

a cystitis developed during an attack of typhoid fever " owing 
to infection with the typhoid bacillus," and the organism 
could still be demonstrated in the urine after seven years. 
In the same paper Young reported two additional cases of 
chronic cystitis due to the typhoid bacillus. 

Commenting on his own cases of typhoid bacilluria Klinger 
remarks that 7 of the 8 were women, and that it is easily 
conceivable that the organisms found their way from the 
anus — all of them passed typhoid bacilli in the feces — to 
the vulva, and were then mechanically washed away by the 
urine, in specimens of which they could multiply, thus 
readily leading to their discovery. That such a possibility 
exists may be conceded, and in two of his cases it is supported 
by the finding of a sterile urine when this was obtained by 
catheter. On the other hand, such an explanation would only 
be warrantable if a catheterized specimen could be shown 
to be sterile. 

Intermittent Elimination of the Organisms. — The elimination 
of the bacilli in the feces is somewhat variable. During the 
course of the malady and the beginning of convalescence 
the organisms usually appear periodically — in Schuben, as 
the Germans say. Subsequently, when the chronic carrier 
stage has been reached the elimination tends to become 
continuous. Lentz has studied this phase of the problem 
with special care. He states that following a sharp ascent 
in the curve of elimination at the beginning of convalescence, 
this is usually followed by a corresponding drop or even an 
entire cessation in their elimination, but that beginning with 
the fourth afebrile week there is again a gradual rise which 
soon reaches a certain level which is thereafter maintained, 
subject to but inconsiderable fluctuations. Such at any rate 
appears to be the rule from which there are, however, not 
infrequent exceptions, and many writers warn insistently 
against the idea that a single or even several negative find- 
ings may be regarded as ruling out the carrier state. It is 
well to bear this in mind and to take such steps when inves- 
tigating a doubtful case as will favor their elimination at 
the time. (See Recognition of Carriers.) 



72 TYPHOID FEVER 

The number of organisms which is eliminated at one time 
is variable. On the one hand, not a single colony may be 
found on the plates; at other times there may be but one 
or two, while on still other occasions almost a pure culture 
is obtained, and this not only in different people, but in one 
and the same person. As a rule they are present in enormous 
numbers and demonstrable without recourse to the use of 
any " enriching" medium. 

Tendency of Women to Become Carriers. — A very important 
observation which has been made by all observers is the 
marked tendency which women, and more particularly mar- 
ried women, manifest to become carriers. As a matter of fact, 
fully 82 per cent, of all chronic carriers are females, and even 
among the temporary carriers 60 per cent, are of that sex. 
Children, on the other hand, while they represent 35 per cent, 
of the temporary carriers, only become chronic carriers to 
the extent of 4 per cent. The remarkable tendency of women 
to become chronic carriers is particularly important, if we 
bear in mind their intimate association with the handling 
and preparation of food (see below) . 

Habitat of the Organisms. — Regarding the probable focus 
at which the bacilli that appear in the feces develop, a great 
deal of excellent work has been done. v. Drigalski 7 thus 
ascertained that the typhoid infection is by no means con- 
fined to the intestinal tract and its associated glandular 
organs. By cultural methods he showed that as one ascends 
the intestinal tract from the rectum the number of typhoid 
bacilli increases, and that in the duodenum and the upper 
portion of the jejunum one frequently meets with enormous 
numbers of typhoid bacilli in nearly or actually pure culture. 
In this respect v. Drigalski's findings agree exactly with those 
of Jiirgens. 20 But he further made the interesting observa- 
tion that a similar state of affairs exists in the stomach, 
where the organisms could always be demonstrated in large 
numbers, in spite of the prevailing acid reaction, whereas 
frequently it was most difficult to demonstrate the organisms 
at all in the bases of the intestinal ulcers — contrary to what 
one would have expected according to our former notions, 
v. Drigalski further demonstrated their presence in the 



HABITAT OF THE ORGANISMS 73 

esophagus, in the coating of the tongue, in the tonsils, in the 
lungs, in the trachea; in short, in practically all organs of the 
body, but in addition also— and this interests us particularly — 
in the bile, where they could always be found. 

Corresponding observations on the occurrence of typhoid 
bacilli in the bile passages had previously already been made 
by a number of observers. Anton and Futterer 21 had thus 
demonstrated the presence of the organisms not only in the 
gall-bladder but also in gall-stones. Chiari, 22 and Chiari and 
Kraus 23 reported their frequent presence in the bile following 
typhoid infection, and Kanthack, 24 like v. Drigalski, had 
encountered them in every instance. These older observa- 
tions now gained new importance. 

Regarding the manner in which the organisms reached the 
gall-bladder there was uncertainty. The prevailing view had 
been that they gained access from the intestines through the 
common duct. Blachstein and Welch, 25 however, showed in 
the animal experiment that the organisms appear in the 
gall-bladder following intravenous injection, and that they 
may be demonstrable here after a long while — in one instance 
after 128 days — and at a time when all other organs are 
sterile. These results were fully confirmed by Doerr, 26 who 
also could demonstrate the organisms after 120 days, but 
he points out that such a long-continued existence in the 
gall-bladder was exceptional, and that after a certain length 
of time they usually disappear. He suggests that the dura- 
tion of their sojourn in the gall-bladder may be dependent 
upon the extent to which the walls of the latter become 
diseased. It is interesting to note that in no case was there 
an absence of inflammatory reaction, though at times this 
was slight. He adds that the blood and other organs were 
found sterile already after two weeks. 

Such observations evidently fully justified the statement 
made by Chiari 27 at a meeting of the Section of Internal 
Medicine of the Association of German Naturalists in 1907, 
.to the effect that typhoid bacilli enter the bile passages from 
the blood in every case of typhoid fever, that they produce 
inflammation and can then multiply indefinitely. 

On the basis of these observations, which were further 



74 TYPHOID FEVER 

supported by the long experience gained in the Pathological- 
anatomical and Bacteriological Institutes of Strassburg, 
Forster 9 then expressed the opinion that the gall-bladder con- 
stitutes the source of the fecal typhoid bacilli found in carriers. 
As regards the modus operandi by which the bacilli secure 
permanent lodgment in the gall-bladder, Forster expressed 
the opinion that their primary appearance in the biliary 
passages leads to a certain degree of inflammation, with con- 
sequent exudation. He seems to regard the latter as essen- 
tial to the development of the organisms, and states that in 
pure bile they do not multiply, while bile mixed with a little 
serum constitutes an excellent culture medium. This, how- 
ever, is in contradiction to the experience of other observers, 
such as v. Drigalski and Doerr, who noted that the typhoid 
bacilli grew readily though slowly and steadily in human bile. 
Doerr mentions specifically that so far as normal human bile 
is concerned there is no evidence whatever of a bactericidal 
effect, and it may be added that the same was noted when 
typhoid bacilli were inoculated into broth containing a 
mixture of bile and immune serum. Be this as it may, the 
fact remains that having once reached the gall-bladder they 
may here find lodgment and multiply indefinitely. In some 
manner, however, the process of inflammation is evidently of 
great influence upon the duration of their sojourn. Doerr, 
in connection with his animal experiments, thus noted that 
when the inflammation subsided, the bacilli also disappeared, 
while they remained if the inflammation continued. Irre- 
spective then of the question whether exuded serum is essen- 
tial to their growth, the fact remains that the inflammatory 
process in some manner has to do not only with their 
presence, but also with their continued presence. The correct- 
ness of this view can, of course, also be tested at the operating 
or the postmortem table in the case of chronic carriers who 
have passed through their typhoid attack long before. Levy 
and Kayser 28 seem to have been the first ones to report find- 
ings in this direction in a carrier whose condition had been 
recognized during life. This patient had typhoid fever in 
1903 and developed the carrier condition at that time. 
Death occurred in 1906, and at the autopsy typhoid bacilli 



THE CARRIER STATE AND GALL-STONES 75 

were isolated from the contents of the inflamed gall-bladder 
in large numbers and in pure culture. Corresponding obser- 
vations have since been made by many observers, such as 
Nieter and Liefmann, 30 Gould and Quails, 31 Bindsell, 32 Ham- 
mond 29 and others. It is noteworthy that some of these 
writers dwell upon the thickened condition of the walls of 
the gall-bladder, and the fact that typhoid bacilli could be 
isolated therefrom. Their occurrence in this locality is inter- 
esting from two points of view: It suggests, on the one hand, 
that the infection of the contents of the gall-bladder may 
occur not only through the bile which enters through the 
cystic duct, but through the blood supply of the gall-bladder 
wall itself. On the other hand, it explains why drainage of 
the gall-bladder (v. i.) may be insufficient to remove the 
carrier state, and why cholecystectomy, other things being 
equal, is preferable to cholecystotomy as a method of treat- 
ment. 

Association of the Carrier State with the Existence of Gall- 
stones. — As I have already pointed out, all investigators who 
have studied the problem of chronic carriers have noted the 
remarkable tendency of females in this direction. Forster 9 
thus found that of 194 temporary carriers, 29 per cent, were 
men, 45 per cent, women and 26 per cent, children younger 
than fifteen years of age, while of 173 cases of the chronic 
type, 79 per cent, were adult females and only 17 per cent, 
men and 4 per cent, children. It was this fact which caused 
Forster to suspect that a causal relationship might exist 
between the carrier condition and the development of gall- 
stones. The latter, as Rosenheim 33 first pointed out, and 
as has since been abundantly confirmed, is likewise much 
more common among women than in men (occurring in 
but one male to three females), while children are prac- 
tically exempt. Just as the majority of gall-stone victims — 
about 90 per cent. — moreover, present hardly any or no 
symptoms, pointing to the existence of gall-stones, so also 
do fully 85 per cent, of the permanent carriers give no indi- 
cation of disease of the gall-bladder, which nevertheless 
exists. This has raised the question whether the infection 
of the gall-bladder gives rise to the formation of the stones 



76 TYPHOID FEVER 

or whether the existence of stones perhaps predisposes to the 
development or the continued existence of the carrier state. 
It is, of course, quite conceivable that an individual having 
gall-stones may at some time in the future be stricken with 
typhoid and ultimately become a chronic carrier, in which 
case the original cause for the development of the gall-stones 
would still remain in the dark. The first possibility therefore 
suggests itself as a more fruitful problem for investigation. 
A review of the literature from this point of view reveals a 
number of observations of great interest, which suggest that 
a typhoid infection of the gall-bladder may actually lead to 
the formation of stones. Doerr (I. c.) thus mentions that 
whereas gall-stones are never found in normal rabbits, he 
met with two concretions of the size of a lentil, in one animal 
which had been injected intravenously with typhoid bacilli 
forty days before. He adds that typhoid bacilli were found 
in abundance in the interior of the concretions. He also 
cites certain findings by Richardson, 34 who succeeded in 
experimentally producing concretions in rabbits by the injec- 
tion into the gall-bladder of agglutinated typhoid bacilli. 
The discovery of typhoid bacilli in the interior of human gall- 
stones, as first noted by Fiitterer (I. c), Blumenthal, 11 Levy 
and Kayser, 28 and since then by practically everyone who has 
taken the pains to make the requisite bacteriological examina- 
tions, coupled with the large number of clinical observations, 
to the effect that many individuals in whom gall-stones were 
found gave a history of typhoid fever in the past, and pre- 
ceding the first appearance of symptoms referable to the 
gall-bladder, all suggest that an attack of typhoid fever pre- 
disposes to the development of gall-stones, particularly in 
females, and is probably responsible for their formation. 

I have emphasized the association of typhoid fever with the 
development of gall-stones and the carrier condition for the 
reason that in a search for carriers special attention should be 
paid to individuals who complain or have complained of symp- 
toms, however slight, in connection with the gall-bladder. 

The important question, of course, arises whether typhoid 
bacilli which have once gained access to the intestinal canal 
can continue their existence here, irrespective of the con- 



VIRULENCE OF THE ORGANISMS 77 

tinuation of the inflammatory process in the gall-bladder. 
Forster denies this possibility, while other observers, such as 
Lentz, suggest that they may do so, basing their opinion upon 
the enormous number of organisms which are usually found 
in the feces and the fact that they may appear in almost 
pure culture, which would suggest that they had crowded 
out the colon bacillus by their growth and had taken its 
place. The view that they cannot maintain themselves in 
the intestinal tract in the absence of continuous reinforce- 
ments from the gall-bladder is, however, more likely correct. 
That the organisms may multiply in the intestinal tract 
for a while and may even force the colon bacilli into the back- 
ground is possible and indeed probable. But, if we remember 
the practical impossibility of artificially replacing the colon 
bacillus by other organisms, unless these are constantly 
supplied anew, as in the case of the Bacillus bulgaricus, it 
does not seem likely that the large numbers of typhoid bacilli 
in chronic carriers could develop without constant reinforce- 
ments. This is further suggested by the fact that the 
majority of typhoid cases do not become chronic carriers, 
notwithstanding the almost invariable presence of the organ- 
isms in the feces at some stage of the disease, and is also 
supported by the observation of cases in which following 
operation for gall-stones and evacuation of the gall-bladder 
the organisms disappeared both from the bile and the intes- 
tinal contents. 

Dehler 35 mentions two cases in which he did a cholecysto- 
tomy, with the result that the carrying condition disappeared. 
Further investigations in this direction are, however, neces- 
sary, and it would seem well worth while to repeat the experi- 
ments of Blachstein and Welch and Doerr described above, 
and to supplement their studies by a control of the animal 
feces. In the postmortem room, moreover, the contents of 
the gall-bladder of every chronic fecal carrier should be 
carefully examined, with the idea in mind of determining 
whether a sterile gall-bladder could ever be associated with 
the presence of typhoid bacilli in the feces. 

Virulence of the Organisms. — Another question that has 
suggested itself in connection with the carrier problem is, 



78 TYPHOID FEVER 

whether or not the typhoid bacilli which we encounter in 
people who for the most part at any rate appear healthy and 
well, are actually virulent organisms and capable of infecting 
others. Bearing in mind the loss of virulence which certain 
organisms undergo when kept under artificial cultivation, a 
loss of virulence in the human being also, after thorough 
adaptation to its new surroundings, would, a priori, not seem 
impossible. So far as such a question can be answered by the 
animal experiment, the evidence is quite conclusive that there 
is no loss of pathogenic activity, as it has been shown that the 
limits of virulence in the case of carrier cultures are the same 
as with those obtained from the feces, the blood and the spleen 
of typhoid patients. Positive evidence of this order is particu- 
larly valuable, while negative evidence would in itself not 
have disproved the possibility that the organisms might after 
all have retained the same degree of virulence for the human 
being. Conclusive evidence of the virulence of the organ- 
isms in question for man is, however, afforded by the obser- 
vation that many outbreaks of the malady have been traced 
directly to carriers. 

It has been suggested by Hilgermann 36 that the relative 
infrequency of infections in the entourage of carriers may 
be due to variations in the virulence of the organism and that 
this diminishes with the continued parasitic existence of the 
latter in the organs of its host. As a matter of fact, there is 
no experimental evidence to support such a view, and it is 
negative, moreover, by the observation that the carrier can 
infect throughout a long period of years. Hilgermann's 
further suggestion that infection can only occur through a 
carrier if a special predisposition exists on the part of the 
recipient, while likewise unsupported by experimental data, 
seems more reasonable. But, on the other hand, one must 
not forget that the carrier's fingers need not always be con- 
taminated, and, moreover, that even though contaminated, 
they might not always carry an infecting dose, and that even 
though the quantity be sufficient for the infection of one 
individual, its distribution in the food and among several 
recipients would tend to diminish it sufficiently to prevent 
infection, 



CARRIERS AND CASES OF TYPHOID FEVER 79 

Numerical Relation between Carriers and Cases of Typhoid 
Fever. — Before passing on to a recital of outbreaks, which 
have been traced to the activity of carriers, we shall briefly 
consider what knowledge we actually possess regarding the 
numerical extent to which carriers have been proved to be 
responsible for the dissemination of the disease. It may be 
stated in advance that our knowledge in this respect is as 
yet quite meager, owing to the insignificant part which 
health department laboratories in many countries have thus 
far taken in the study of sanitary problems. The figures 
obtained at the various Stations established by the Prussian 
Typhoid Commission show conclusively, however, conserva- 
tive as they are, that the carriers play a very important role 
in the dissemination of the disease. It will be recalled that 
only a relatively small number of typhoids become chronic 
carriers, but that even so they are sufficiently numerous as 
to constitute from 0.3 to 0.4 per cent, of the total population 
of any large city. Calculated out for a city such as New 
York, this would correspond to approximately 25,000 cases! 
With such an enormous number of carriers at large, one is on 
first thought surprised that typhoid is not much more preva- 
lent than is actually the case. But we must remember that 
the location of the bacilli in the intestinal tract or the urine 
renders their dissemination among human beings much more 
difficult as compared with other organisms which are dis- 
tributed through the discharges from the throat and nose, 
so long as distribution by a common commodity such as the 
water or milk supply can be eliminated. The chances of 
infection through direct contact with the patient and his 
immediate surroundings are, of course, much greater than 
through the carrier. At the same time there is greater 
indirect danger from a carrier for the reason that the number 
of persons with whom he is brought into contact is certain 
to be larger than would be the case in a sick room. In a study 
of a large number of cases we accordingly find that the 
majority of typhoids have acquired the disease through con- 
tact with typhoid patients, but that of the remainder a very 
considerable portion can be referred to carriers. 

Regarding the actual percentage of such cases as compared 



80 TYPHOID FEVER 

with the total number, there is, however, a great deal of 
uncertainty. Frosch 37 in an analysis of 978 cases which had 
been fairly definitely traced to their source of infection found 
that 642, viz., 65.04 per cent., were contact cases. In 104 
the question was still an open one whether the infection had 
occurred through direct or indirect contact, but as 3 cases 
had developed among persons who had been living in more 
or less intimate association with typhoid patients the writer 
thinks these should be added to the number of contacts, 
which would increase the percentage to 76.2. There remain 
then 232 cases, viz., 23.7 per cent., which were attributa- 
ble to indirect infection — through drinking water, bath- 
ing, milk and other articles of food. Of the 746 cases, only 
49 could be referred to carriers, i. e., only 5.01 per cent, of 
the definitely traced cases. This low percentage, on first 
consideration, would suggest that the danger from the car- 
rier was relatively slight, but it must not be forgotten that 
Frosch 's series of 978 traced cases corresponds to a total of 
2080, and hence represents but 47.7 per cent, of that number, 
leaving 52.3 per cent, unexplained. The data from which 
Frosch's figures were drawn were obtained by sending out a 
questionnaire and analyzing the returned answers. It does 
not require much imagination to recognize why the majority 
of the "traced" cases should have been contact cases pure 
and simple and not due to carriers, for it is evident that a 
second case occurring in the surroundings of a first case 
would naturally be attributed to this source, while the 
answer as regards the origin of the latter would most likely 
have been "unknown." But it is just the "unknowns'' 
which we must look upon with special suspicion as being 
possibly due to carriers, and if we bear in mind the difficulty 
which is so often experienced in finding the carrier, and the 
fact that when he is found he is so often proved responsible 
for a larger number of infections than the patient who is 
confined to bed and in contact with only a small number of 
people, we will also realize that definite conclusions regarding 
the actual role of the carrier in the distribution of the disease 
can certainly not be reached by an analysis of information 
that has been collected in such a manner. As a matter of 



MANNER OF INFECTION 81 

fact, Frosch's data do not accord at all with the findings 
obtained at Strassburg, as the result of an actual investi- 
gation of concrete cases. 

At the Strassburg Station 386 cases of typhoid fever were 
studied from January, 1906, to the end of June, 1907. Of 
these, 77 cases, i. e., 20 per cent., could be traced to carriers; 
117 cases, viz., 30 per cent., were regarded as contact cases, 
while in 45, i. e., 11 per cent., the source of the infection could 
not be determined. The remainder were caused by infection 
through drinking water, milk, etc. By distributing the 
unexplained 11 per cent, among the three groups the carrier 
class would be increased to 22 per cent. This figure, however, 
does not yet express the full extent to which carriers are 
responsible for the dissemination of the disease, for of the 
water and milk cases a large number are now definitely known 
to be due to carriers. If we distribute these between the 
carriers and contacts in the proportion of two to three, the 
carrier percentage would be increased to 40, which would 
seem a conservative estimate, and would indicate what a 
formidable factor they represent in the dissemination of the 
disease. These figures applied to the typhoid cases occurring 
in a city like New York would indicate that for 1914, for 
example, 1004 were referable to this source. As I have said 
before, the healthy carrier is far more dangerous than the 
patient. In the case of the latter the danger is a manifest 
one, while in the case of the former it is hidden. 

Manner of Infection. — Regarding the manner in which the 
carrier can infect others, many possibilities, of course, exist. 
Whenever infected fecal material or urine finds its way into 
the drinking water of a community, ideal conditions naturally 
exist for the development of epidemics, the extent of which 
will be proportionate to the number of people using the 
water. In districts in which sewage is used for the purpose 
of fertilizing farms or gardens, outbreaks may be expected 
among those using uncooked products in their diet. In the 
past it was customary among agriculturalists to sprinkle 
their lettuce with sewage in order to keep it "fresh," and 
many outbreaks of the disease have been traced to such a 
source. The peculiar danger of the carrier, however, which 
6 



82 TYPHOID FEVER 

distinguishes his type of infectiousness from that of the 
typhoid patient, lies in his relation, through direct contact, 
with the food supply of a community. We thus find that on 
farms it is the carrier milking the cows who is so frequently 
responsible for outbreaks of the disease, the extent of which 
may equal that referable to infection of the water supply. 
In institutional outbreaks or in house epidemics similarly we 
frequently find the cook to be the responsible factor, which 
means, of course, that the individual has soiled his or her 
hands with fecal matter or urine and has transferred the 
responsible organisms to the food. The amount of harm 
which a single individual can thus cause is perfectly amazing. 
In a recent analysis made by the Division of Preventable 
Diseases of the Minnesota State Board of Health, 38 in the 
case of 37 carriers, it was found that 220 cases of typhoid 
fever, including 12 fatalities, could be traced to such indi- 
viduals, giving an average of 6 cases per carrier. In the case 
of the now world-famed Typhoid Mary 39 of New York, 57 
cases of the disease with 3 deaths could be traced to this one 
carrier. In one instance related by Kossel, 40 an outbreak 
of 25 cases was found to be due to a single carrier who was 
employed on a farm which furnished milk to the stricken 
individuals. 

Examples Illustrating the Activity of Carriers. — To pass on 
to a recital of a number of concrete cases illustrating the 
connection between outbreaks of the disease and carriers, I 
would head the list with the record of Typhoid Mary, to 
which I have just referred. 

The Case of Typhoid Mary. 39 — The earlier portion of this 
woman's history has been related by Park in the third edition 
of his Pathogenic Microorganisms, published in 1908, and 
reads as follows: 

"Five years ago a visitor of the family in which the woman 
was cook developed typhoid fever some ten days after enter- 
ing the household. The cook had been with the family for 
three years, and it is difficult to judge which infected the other. 
In 1901 the cook went to another family. One month later 
the laundress was taken ill. 

In 1902 the cook obtained a new place. Two weeks after 



EXAMPLES ILLUSTRATING ACTIVITY OF CARRIERS 83 

arrival the laundress was taken ill with typhoid fever; in a 
week a second case developed and soon seven members of the 
household were sick. 

In 1904 the cook went to Long Island. There were four 
in the family, as well as seven servants. Arrived June 1. 
Within three weeks after arrival four servants were attacked . 
The servants lived together. 

In 1906 the cook went to Oyster Bay. Between August 
27 and September 3 six out of eleven in the house were 
attacked with typhoid. At this time the cook was first 
suspected. She went then to Tuxedo and remained there 
from September 21 to October 27. On October 5 the laundress 
developed typhoid fever. 

In 1907 at New York, two months after the cook's arrival, 
two cases developed, one of which proved fatal. Altogether 
during five years this cook is known to have been the cause 
of twenty-six cases of typhoid fever. 

She was removed to a hospital March 19, 1907. Cultures 
taken every few days showed bacilli off and on for fourteen 
months. Sometimes the stools contained enormous numbers 
of typhoid bacilli and again for days none would be found. 

The woman then appears to have escaped from observation 
until 1914. In October of that year she was engaged as cook 
in the Sloan Hospital for Women of New York. In January 
and February of 1915 an outbreak of typhoid fever occurred, 
principally among the nurses, doctors and help of the insti- 
tution, involving twenty-five cases. 

A careful investigation into the food and water supply of 
the hospital showed no evidence of outside contamination. 

Fecal and Widal specimens were then taken from the entire 
kitchen and pantry force, but nothing was found beyond a 
faintly positive agglutination reaction in the case of the cook, 
who gave a history of having had typhoid fever a number of 
years before. Three fecal specimens from her were examined 
at the hospital, but no typhoid bacilli found. The woman 
then left the premises on a few hours' leave and did not return 
or leave her address. She was located, however, with a great 
deal of difficulty and specimens of her feces obtained, which 
she submitted under an assumed name and while she believed 



84 TYPHOID FEVER 

that she was eluding the Health Department. While under 
observation she aroused the suspicions of the Health Depart- 
ment, and it was surmised that she might be the famous 
Typhoid Mary (Mary Mallon). Investigation established 
that this was indeed the case. She was then taken to River- 
side Hospital and carefully investigated, the findings proving 
conclusively that she was a chronic typhoid carrier. 

A subsequent study of her career showed that she had 
infected still other individuals beyond those already men- 
tioned, and that she may have given rise to the well-known 
water-borne outbreak of typhoid fever in Ithaca, N. Y., in 
1903, embracing over 1300 cases. As a matter of fact it 
could be shown that a person by the name of Mary Mallon 
had been employed as a cook in the vicinity of the places 
where the first case appeared and from which the contami- 
nation of the water supply occurred. 

Another interesting instance illustrating the danger of 
typhoid carriers to others has been reported by Ravenel 46 as 
follows : 

In the fall of 1910 Mr. A. moved from Minnesota to the 
town of G., Wisconsin, bringing with him his wife and three 
boys. He bought a farm four miles northeast of the village. 
In December, 1909, Mr. A. had been operated on in St. Paul 
for pyonephrosis, and a tumor mass weighing five pounds 
removed. No bacteriologic examination was made. One of 
the doctors who assisted at the operation states that six 
months before he had treated Mr. A. for typhoid fever. 
About the time of moving to Wisconsin the eldest son had 
typhoid fever, and soon after the two other sons and their 
mother came down with the disease. 

Mr. B., with his family consisting of his wife, two boys and 
a girl, moved from Minnesota to Wisconsin about the same 
time, having purchased a farm in the immediate neighbor- 
hood of Mr. A. While the buildings on this place were being 
put in order Mr. B.'s family stayed at the home of Mr. A., 
with the apparent result that first the daughter, and soon 
after Mr. B. and the two sons came down with typhoid fever. 

In the fall of 1911 Miss C, a niece of Mr. A., came from 
St. Paul to teach in the public schools. She was in the habit 



EXAMPLES ILLUSTRATING ACTIVITY OF CARRIERS 85 

of spending the week-end at the house of Mr. A. After six 
weeks' residence in the town of G. she became ill with typhoid 
fever. 

At the same time a sister of Mr. A. visited him and soon 
after returning to her home suffered from typhoid fever also. 

About August 15, 1911, Mr. D. visited at the home of Mr. 
A. and took supper with him. September 20 Mr. D. entered 
a hospital after having been sick for some days and a diag- 
nosis of typhoid fever was made. His illness began during 
the first week of September. 

In the spring of 1912 two young men, E. and F., who were 
working at the home of Mr. A., both contracted typhoid 
fever. 

In the fall of the same year Mrs. G., a sister of Mrs. A., 
accompanied by her son, spent a few weeks at the home of 
Mr. A. Soon after returning home both contracted typhoid 
fever. 

In the latter part of 1912 or January, 1913, Mr. H., a 
brother of E., spent a night at the home of Mr. A., and 
twelve days afterward came down with typhoid fever. 

In June, 1913, Miss I., a niece of Mr. A., living near him, 
suffered from typhoid fever. There had been frequent 
visiting between the two families. 

On or about October 15, 1913, Mr. J. took the Rev. K., 
his wife and two children to the home of Mr. A. for a visit. 
They did not take a meal at the house, but the children 
became hungry and cookies were provided. October 28 the 
Rev. K. bought butter from Mr. A. for table use, and on 
November 2 Mr. A. and family dined at the home of the 
Rev. K. On November 11 the two children of the Rev. K. 
became ill with typhoid fever, and on November 30 Mrs. 
K. and her husband also went down with the disease, 
Mrs. K. dying. 

It thus appears that 21 cases of typhoid fever occurred 
among persons in this community, or those who had visited 
there, and all of them had been in contact for longer or shorter 
periods of time with Mr. A. 

In June, 1913, an investigation was made by the health 
authorities, and it was ascertained that Mr. A. and one son 



86 TYPHOID FEVER 

gave a positive Widal reaction and that the urine of Mr. A. 
contained typhoid bacilli; cultures from the feces were nega- 
tive. Subsequent examinations gave the same result. The 
water supply of the community was examined and found to be 
above suspicion, and there was no typhoid in the town except 
among those persons who had been in contact with Mr. A. 
As regards the manner of infection it would seem that this 
took place in the case of the Rev. K. and his family, at least, 
through some dairy products such as butter which the indi- 
vidual in question was known to have purchased from Mr. A. 

Another interesting case which illustrates the important 
bearing which carriers have on milk epidemics is related by 
Kossel. 40 

In the town of O. there occurred 25 cases of typhoid fever 
during the summer of 1906 — 3 about the middle of May, 5 
toward the end of June, 6 about the middle of July and 11 
about the middle of August; 21 of the 25 obtained their milk 
from the same dairy. The dealer in turn was supplied by 
three farms, one of which, B., had been under suspicion for a 
number of years. This farm furnished milk also to the town 
of F., where it had also been noticed that only those developed 
the disease who had been supplied from farm B. The health 
department had repeatedly investigated the situation, had 
made certain suggestions, which were carried out, but with- 
out producing the desired result — all this it may be added at 
a time when but little was as yet known of carriers. When 
attention was again directed to farm B. in connection with 
the outbreak of the disease at O., Kossel was asked to make an 
investigation along the new lines which had been suggested 
through the findings of the Prussian Typhoid Commission. 

Farm B. was found to belong to village B., where epidemics 
of considerable dimensions had occurred in 1857 and 1872, 
since when the disease had never entirely disappeared, but 
had practically only attacked children and newcomers. The 
small river flowing through B. which furnished the drinking 
water supply had been suspected and wells sunk instead. 
The results were apparently beneficial, since laborers coming 
from outside, who in the past had usually developed the dis- 
ease in from four to six weeks after their arrival, now rarelv 



EXAMPLES ILLUSTRATING ACTIVITY OF CARRIERS 87 

became ill. That the disease had not been entirely eradi- 
cated, however, was shown by the development of 1 case 
in the month of January, 1906, and the outbreak in both O. 
and F. Some of the milk sent out from farm B. was mixed 
with milk from the village B., but as no village cases had 
occurred, save certain ones which might have been referred 
to the farm, the conclusion was reached that the farm itself 
constituted the source of the infection. The occurrence of 
the cases in O., in groups, suggested a periodic infection of the 
milk and not of the entire amount. 

Specimens of fecal material were ordered from the fifteen 
employees on the farm. Examination showed that one of 
these contained typhoid bacilli in large numbers (October, 
1906). The specimen in question came from a man whose 
duty it was to look after the pigs, but it was ascertained that 
he at times helped in milking the cows. The man had been 
employed on the farm for about twenty years. He gave no 
definite history of antecedent typhoid, but coming from the 
village B. it is quite conceivable that he had been infected 
there. The man was now removed from all contact with the 
dairy department and no more cases of typhoid developed 
thereafter until May, 1907, when 1 case appeared in the 
village B., and it was found that the same carrier had again 
been employed in the dairy. That the individual in question 
was a true chronic carrier was shown by the demonstration 
of typhoid bacilli in his feces on July 22, 1907. 

An account of an extensive milk epidemic due to a single 
carrier has also been related by Bolduan and Noble. 41 In this 
instance a sudden increase in the number of typhoid cases 
occurred toward the end of August, 1909, in the boroughs of 
Manhattan and the Bronx, and investigation showed that a 
certain milk supply was common to almost all. This was 
immediately shut off, but even so some 380 cases of the dis- 
ease developed. Following the lead of the milk supply it was 
found that the infected milk came from Camden, N. Y., and 
that there had been an unusual prevalence of typhoid fever 
at this place for years. A tabulation of all the cases in the 
village in 1908 and 1909 — 27 in number — showed that 20 re- 
ceived milk from dairy X. The medical history of the dairy- 



88 TYPHOID FEVER 

man's family revealed the following: The man himself had 
had typhoid fever in 1863 or 1864 (forty-six years ago). He 
came to Camden in 1866 and began to sell milk from the same 
dairy, as at present, in 1873. In 1878 his two-year-old 
daughter had "enteric fever.''" In 1886 his son-in-law, who 
was then working on the farm as a hired man, was very ill 
with a fever lasting several weeks — then termed " gastric 
fever." In 1893 another daughter was ill with "typhoid 
fever." In 1897 still another daughter was ill, in the fall of 
the year, with "intermittent fever," with which she was 
confined to bed for two or three weeks continuously, and 
which attack was followed during convalescence by a second 
attack, during which time the patient was very ill. In 1903 
a hired man left the farm and was taken ill ten days later 
with "typhoid fever." In 1909 another hired man, while on 
the farm, sickened with typhoid fever and died. 

An examination of the feces of the entire household was 
now made and revealed almost a pure culture of the typhoid 
bacillus in the case of the dairyman himself. Similar results 
were obtained a month later, and again after a year, so that 
the status of the dairyman as a chronic carrier, probably of 
forty-six years' duration, seems pretty definitely established. 

The question now arose whether this particular man could 
be connected with the outbreak of the disease in Manhattan 
and the Bronx, which in turn had led to the investigation. 

It was found that the man's son-in-law was also engaged 
in the dairy business and sent his milk to the creamery at 
Camden, from which the wholesale dealer in New York 
received his supply. Dairyman X., himself, furnished no 
milk directly to the creamery, but supplied the village. It 
was ascertained, however, that whenever he returned from 
his route to his farm he left the milk that was left over from 
the trip, with his son-in-law, who included this in his supply 
to the creamery. Milk had thus been received from farm X. 
during the month preceding the onset of the city cases, and 
there is practically no doubt that this constituted the chain 
of infection. 

In commenting on this outbreak Bolduan points out the 



EXAMPLES ILLUSTRATING ACTIVITY OF CARRIERS 89 

great danger of having a bacillus carrier on a dairy, even 
when the individual, as in the present instance, was cleanly 
himself and kept his home and dairy much cleaner than the 
average dairyman. 

A very interesting outbreak of typhoid fever on shipboard, 
due to a carrier, is related by Sawyer, 42 which illustrates that 
a carrier may be of great danger to others even when not 
occupied in the preparation or handling of food. In this 
instance 26 cases of the disease developed within three and a 
half years on a ship carrying 21 men, and were all traced to 
one carrier. The vessel in question was a lumber steamer, 
and its relation to the appearance of typhoid among members 
of the crew was so well known to sailors that the ship was 
called the fever ship, and it was difficult to secure desirable 
men for its crew. On investigation the conclusion was 
reached, through a process of elimination, that the series of 
cases of typhoid fever among the crew arose from a focus on 
board the ship itself. The evidence finally tended to indicate 
that a certain member of the crew was a carrier. The serum 
of this man gave a positive Widal reaction and the typhoid 
bacillus was isolated from his stools. The man himself had 
had typhoid fever four years previously; he had nothing 
whatever to do with the handling of the food, but had evi- 
dently infected the others through the use of a common 
dipper which was employed by the crew in procuring water 
from an open cask which was kept on deck. 

Sawyer remarks in conclusion that if the staff of the 
hospital at which the man had been treated for his typhoid 
had discovered the bacillus in his stools at the time of his 
discharge the other 26 cases with 4 deaths might not have 
occurred. 

Pus Carriers. — While the majority of typhoid carriers are 
fecal carriers or urinary carriers, or both at the same time, it 
should be borne in mind, when investigating an outbreak of 
the disease, that still other possibilities exist. An instructive 
instance has thus been reported by Bigelow. 43 In this case 
a house epidemic was traced to an individual who had had 
au attack of typhoid fever some months previously, followed 



90 TYPHOID FEVER 

by necrosis and abscess formation about the sternum. At 
the time of the investigation his blood gave a positive Widal 
reaction, while the urine and feces were found free from 
typhoid bacilli on three different examinations. In the pus 
which was obtained from two small sinuses communicating 
with the sternum, the organisms in question were, however, 
obtained on every occasion. The infection of the other mem- 
bers of the household had apparently taken place through 
fruit which the carrier had gathered some days before the 
onset of their attacks. 

The Recognition of Typhoid Carriers. — The recognition of 
typhoid carriers of the fecal type is facilitated by the fact 
that the blood serum of such individuals usually gives the 
Widal reaction; exceptions occur, but they are relatively 
rare. The discovery of this fact throws a new light upon the 
significance of a positive Widal reaction persisting for many 
years following an attack. Formerly it was thought that 
such an occurrence was a normal event, but in view of our 
present knowledge it would be well to regard all such indi- 
viduals as possible carriers unless the contrary can be proved. 
For reasons already indicated, special attention should be 
directed to females who give a history of typhoid fever, and 
especially so if symptoms pointing to disease of the gall- 
bladder exist or have existed in the past. Not too much 
reliance should be placed upon negative answers on the part 
of individuals, however, as carriers who know themselves 
to be such may purposely attempt to mislead the ex- 
aminer. 

Having thus picked the suspects the next step is to examine 
their feces as well as the urine. So far as the latter is con- 
cerned it is well to bear in mind that typhoid bacilli may 
be present in a perfectly clear urine (Frosch, v. Drigalski, 
Conradi) and that a specimen should accordingly not be 
reported as negative merely because it is not turbid. Pre- 
ceding the collection of the fecal sample it has been recom- 
mended to increase the flow of bile by the administration of 
cholagogues, followed by a mild laxative (3 to 5 grams of 
inspissated ox bile per diem, for several days), with the view 



THE RECOGNITION OF TYPHOID CARRIERS 91 

of washing the organisms into the intestinal tract and thus 
facilitating their finding. This will frequently not be neces- 
sary nor practical, but the procedure may be resorted to in 
special cases. Care, of course, should be exercised to insure 
that the specimens submitted for examination actually come 
from the corresponding individuals. 

Bacteriological Technic. — For the demonstration of typhoid 
bacilli in the feces a large number of cultural methods are 
available. Those most frequently employed are the methods 
of v. Drigalski-Conradi, of Endo, of Krumwiede and of Russel. 
It should be remembered, however, that the majority 
of these methods merely permit a differentiation of the 
typhoid from the colon bacillus, and not from the so-called 
intermediates, nor from the dysentery bacillus. It is hence 
necessary to identify colonies which are manifestly not due to 
the colon bacillus by further cultural methods, notably their 
behavior toward carbohydrate bouillons and litmus milk 
and their response to treatment with corresponding immune 
sera in high dilution. 

From a practical standpoint, of course, the differentiation 
of the typhoid bacillus from the intermediates is not par- 
ticularly important, since what has been said in the foregoing 
pages regarding typhoid fever in connection with the carrier 
question is equally true of paratyphoid. 

In this connection it is well to emphasize the fact that more 
stress should be laid upon the cultural characteristics of 
suspicious colonies than upon their immediate reaction to 
antityphoid sera, bearing in mind that freshly isolated cul- 
tures not infrequently show a considerable degree of resist- 
ance to the action of agglutinins, which is lost, however, after 
a series of transplantations, when their behavior becomes 
typical of the usual laboratory strains. 

A description of the more important methods for the 
isolation of the organisms follows: 

The Drigalski-Conradi Method. — The medium is essentially 
a feebly alkaline, lactose meat infusion agar, to which litmus 
and crystal violet have been added — the latter to inhibit the 
growth of various organisms that may be associated with the 



92 TYPHOID FEVER 

typhoid and colon bacillus in the feces, the former to dis- 
tinguish between organisms that ferment lactose, with acid 
production (colon bacillus) and those that do not (typhoid 
bacillus) . 

Preparation of the Medium. — The meat infusion agar is pre- 
pared in the usual manner. It should contain 10 grams of 
peptone, an equal quantity of nutrose,* 5 grams of salt and 
35 grams of agar to the liter, the infusion itself being made 
from a pound and a half of lean beef or veal. The reaction is 
made neutral or feebly alkaline to litmus. 

To a liter of the hot agar solution are added 130 c.c. of 
hot litmus-lactose solution, prepared as described below: 
the reaction is again tested with litmus paper and readjusted 
to a weak alkaline, after which the mixture is further 
treated with 2 c.c. of a hot sterile 10 per cent, solution of 
sodium carbonate and 10 c.c. of a freshly prepared 0.1 
per cent, solution of crystal violet B in sterile distilled 
water. 

The litmus solution advocated by Drigalski and Conradi 
was that originally recommended by Kubel and Tiemann 
and sold under their name. In its place any sensitive aqueous 
solution of litmus may, however, be used. 130 c.c. are boiled 
for about ten minutes, then treated with 15 grams of chemi- 
cally pure lactose and boiled for fifteen minutes longer. If 
a sediment has formed, the supernatant fluid is decanted and 
the clear solution then added to the hot agar solution, as 
described. The final product may be kept in 100 or 200 c.c. 
lots until needed or it may be plated at once. The Petri 
dishes should be as large as possible (15 to 20 cm. in diameter) 
and covered to a depth of at least 2 mm. with the medium. 
The covers are not replaced until the steam has evaporated 
and the agar is quite firm. Contamination by organisms of 
the air does not occur, owing to the inhibitory action of the 
crystal violet. 

* In lieu of the German product which is now not available, a substitute 
may be employed which is composed of 94 parts of peanut flour, 5 parts of 
casein and 1 part of sodium carbonate (Wallis, R. L. M., Indian Jour. Med. 
Res. Calcutta, April, 1917). 



THE RECOGNITION OF TYPHOID CARRIERS 93 

The examination of the feces is then conducted as follows: 
A small amount of the material in question — a bit the size 
of a split pea — is emulsified in about 10 c.c. of sterile saline 
or broth and a platinum loopful transferred to one of the 
plates. Here it is spread out over the entire surface by the 
aid of a sterile glass rod or a capillary pipette that has been 
sealed and bent to an appropriate angle. 

Each plate is properly labelled and then placed in the 
incubator at 37 ° to 40 ° C. for twenty-four hours. At the end 
of that time it is examined with a hand lens for the presence 
of small transparent blue colonies. The colon colonies are 
large, red and opaque. 

Suspicious colonies are fished, transferred to other media 
and tested in reference to their behavior toward an actively 
agglutinating antityphoid serum. A preliminary test in this 
direction may be conveniently conducted as follows: 

Preliminary agglutination test (macroscopic slide aggluti- 
nation method) . A slide is charged with tiny droplets (large 
platinum loopfuls) of a 1 to 100 dilution of an actively agglu- 
tinating antityphoid, antiparatyphoid A and B, and anti- 
dysentery serum, placed in a row, together with a corre- 
sponding set of saline droplets for control. A tiny bit of the 
suspected colony is now emulsified, first in the saline, and 
then in the corresponding serum droplets. Agglutination will 
occur in the homologous serum within two or three minutes, 
and may be observed directly with the naked eye. 

This method is very satisfactory and is now extensively 
employed in board of health and military hospital labora- 
tories. 

Should a positive reaction be obtained the test may be 
repeated with a pure culture and in various dilutions, the 
organism being further studied in reference to its fermen- 
tative properties* and its behavior, when grown in litmus 
milk. The table on page 94 will show the essential differences 
which exist between the most important representatives of 
the colon-typhoid-dysentery group. 

* For this purpose the Hiss serum-water media are especially to be recom- 
mended (which see). 



94 



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THE RECOGNITION OF TYPHOID CARRIERS 95 

To differentiate between the typhoid, paratyphoid, colon 
and dysentery bacilli, Russell's double sugar agar will also 
be found very convenient (see below). 

The Endo Method. — The medium in question is an ordinary 
neutral or faintly alkaline* 3 per cent, agar to which is added, 
just before use, 1 per cent, of lactose, and a solution of basic 
fuchsin that has been decolorized with sodium sulphite. On 
this medium typhoid and paratyphoid colonies appear color- 
less, while colon colonies, owing to the formation of alde- 
hydes, are red. 

The agar is kept on hand in flasks containing 100 or 200 c.c. 
each. When it is desired to use the medium the agar is 
melted, and, while hot, treated with 1 gram of chemically 
pure lactose and 1 c.c. of the decolorized fuchsin solution, 
per 100 c.c. The latter must always be freshly prepared, to 
which end 10 c.c. of a 10 per cent, aqueous solution of sodium 
sulphite are treated with 1 c.c. of a 10 per cent, solution of 
basic fuchsin in ordinary ethyl alcohol. (The proportions 
may vary a little with different lots of sodium sulphite and 
must be tried out, the point being to obtain a solution that 
is just decolorized.)! 

When the decolorized fuchsin solution is added to the hot 
agar a certain amount of color returns but fades again on 
cooling, leaving the medium either a faint pink or altogether 
colorless. Large plates should be poured at once — to a 
depth of at least 2 mm. — and allowed to cool, with the covers 
off. When the agar has hardened the plates are inoculated 
with a tiny droplet of the fecal emulsion (a bit of fecal matter 
the size of a split pea to 10 c.c. of saline), which is spread 
over the surface with a sterile glass rod or a capillary pipette 
that has been sealed and bent to a convenient angle. They 
are incubated at 37° to 40° C. and examined on the fol- 
lowing day. Suspicious-looking colonies are then fished and 
tested against an actively agglutinating serum by the macro- 

* To litmus. 

t Teague has pointed out that a solution of the sulphite that has been 
heated for twenty minutes at 15 pounds' pressure and layered with petro- 
leum to the extent of about 1 cm. will keep for three weeks or longer. — Jour. 
Am. Med. Assn., 1918, vol. lxx, p. 454. 



96 TYPHOID FEVER 

scopic slide method, as described above, after which they 
may be further studied as indicated. 

Krumwiede' s Method. — The medium employed is a 1.5 
per cent, beef extract (0.3 per cent.) agar, which is made 
just alkaline to litmus and kept on hand in 100 c.c. lots. 
When needed, 1 per cent, of lactose and 0.1 per cent, of glu- 
cose is added to each flask together with a certain quantity 
of brilliant green, and 1 per cent, of Andrade's indicator, 
after which the mixture is brought to the neutral point of the 
indicator by the addition of acid. The principle underlying 
the method is the fact that the brilliant green not only inhib- 
its the growth of all Gram-positive and many Gram-negative 
bacteria, but in certain dilutions also shows a differential 
action upon members of the typhoid-colon group. To this 
end two plates are always prepared in each case, of which 
one corresponds to a dilution of 1 to 500,000 and the other 
to one of 1 to 330,000. The paratyphoids and the Bacillus 
lactis aerogenes are not affected by either dilution; the 
typhoid is restrained by the lower dilution only, while the 
growth of the dysentery bacillus and other members of the 
colon group is inhibited. 

When the plate is viewed at an angle against a dark back- 
ground the typhoid and paratyphoid B colonies appear with 
serrated edges and snowy white, or at most tinged a faint 
pink, owing to fermentation of the glucose, while the acid 
producers are red in consequence of the return of the fuchsin 
color base to the dye itself. 

Krumwiede insists that the particular specimen of brilliant 
green that is available must first be tried out to ascertain the 
exact dilution which will effect the differentiation of the 
typhoid from the colon and dysentery groups. The agar 
must be perfectly clear and of the requisite reaction. His 
instructions for the preparation of the medium follow:* 

When needed the stock agar (see above) is melted and each 
bottle treated with 1 per cent, of Andrade's indicator, when 
acid (n HC1) is added to bring the mixture to the neutral 
point. The indicator is prepared as follows: 100 c.c. of a 

* Taken from Hiss and Zinsser's Bacteriology, Appleton & Co., 3d edition, 
1916, p. 136. 



THE RECOGNITION OF TYPHOID CARRIERS 97 

0.5 per cent, aqueous solution of acid fuchsin are treated 
with 16 c.c. of normal sodium hydrate solution, when in the 
course of about two hours the dye is reduced to the color 
base. If the agar has the proper reaction — and this is of the 
utmost importance — i. e., if it is neutral to Andrade, the color 
is deep red while hot, but fades completely on cooling. In 
order to determine this it is recommended to pour a few cubic 
centimeters of the acidified hot agar into a test-tube and to 
cool this under the tap, when the reaction is finally adjusted 
by adding more acid or alkali, as the case may be. The neu- 
tral point of Andrade's indicator corresponds to an acidity 
of 0.6 to 0.7 per cent, (normal hydrochloric acid) in terms of 
phenolphthalein. 

The requisite amount of lactose and glucose are conve- 
niently added from a sterile stock solution of the two sugars — 
containing 20 per cent, of the former and 2 per cent, of the 
latter respectively; 5 c.c. of this solution represent the requi- 
site quantity for 100 c.c. of the agar. 

To prepare the brilliant green solution 0.1 gram of the dye 
is accurately weighed on a foil, washed with boiling water 
into a 100 c.c. volumetric flask and made up to the mark 
when cool. The flask should be clean and neutral (by test). 
Fresh solutions vary in activity; they keep about one month. 

Different lots of agar with the same dye solution act 
uniformly; a new batch or a new solution must be tested. 

Any variation in the composition of the medium necessi- 
tates a readjustment of the dye concentration; this statement 
cannot be overemphasized. 

As I have stated above, two dilutions of the dye are used, 
and to this end 0.2 c.c. of the stock solution is added to one 
lot of 100 c.c. of agar (giving a dilution of 1 to 500,000) and 
0.3 c.c. to another (giving a dilution of 1 to 330,000). 

Each bottle of 100 c.c. is finally poured into six plates, 
which are then left uncovered until the agar has solidified. 
Porous tops are used in order to secure dry plates and prevent 
diffusion. To this end a piece of filter paper is placed in the 
cover of each plate. 

Duplicate sets — corresponding to the two solutions of the 
dye — are inoculated as above, incubated as usual and exam- 
7 



98 TYPHOID FEVER 

ined the following day. Suspicious-looking colonies are then 
fished and tested as described. 

From the description given it is clear that satisfactory 
results will only be obtained with this method if the medium 
is prepared exactly as indicated, and to judge from personal 
experience even then results will not always be just as 
desired. Kligler has recently recommended the substitution 
of 0.25 c.c. of a 1 per cent, aqueous solution of neutral red per 
100 c.c. of the medium in the place of the Andrade indicator, 
and states that he has found this more useful, as it gives a 
color differentiation which is lacking with the original 
method, the typhoid bacillus leaving the color unchanged. 

RusselVs Double Sugar Medium. — The medium in question 
is a 3 per cent, beef extract agar, which is at first made 0.8 
per cent, acid to phenolphthalein and subsequently brought 
to the neutral point for litmus, a 5 per cent, aqueous solu- 
tion of the latter having previously been added in a quantity 
sufficient to render the medium a distinct purple. This is 
further treated with 1 per cent, of lactose and 0.1 per cent, of 
glucose, which are added dissolved in a little hot water. The 
medium is then tubed and fractionally sterilized in an Arnold 
sterilizer — for fifteen minutes at a time. Before slanting 
Kligler* has suggested that each tube be further treated with 
sterile basic acetate of lead solution to the extent of 0.05 
per cent. (0.5 c.c. of a 1 per cent, solution, per 10 c.c. of 
medium) . 

Suspicious colonies that have been isolated by any one of 
the plating methods described above are inoculated upon this 
medium (using the Kligler formula) , both by streak and stab 
and incubated for twenty-four hours. The typhoid bacillus 
gives a colorless growth on a blue surface, while the end of 
the stab appears red; the medium along the line of the stab, 
moreover, shows a distinct browning. The paratyphoid B 
shows the same features as the typhoid, but produces gas 
bubbles in addition. The dysentery bacilli grow like the 
typhoids, but produce no browning. Paratyphoid A likewise 

* Kligler, I. J.: Modifications of culture media used in the isolation and 
differentiation of typhoid, dysentery and allied bacilli, Abst. of Bact., 1918, 
vol. ii, p. 18. 



THE MANAGEMENT OF TYPHOID CARRIERS 99 

does not produce a brown color but forms gas and acid at 
the bottom of the stab, while the surface remains blue. The 
colon bacillus finally produces acid and bubbles throughout. 

The Management of Typhoid Carriers. — Medical Treatment. — 
When the significance of the typhoid carrier was first realized 
numerous attempts were made to destroy the typhoid bacilli 
in the intestinal canal by disinfectants. As was to be expected, 
in view of what we now know regarding the origin of the 
organisms, the results were absolutely nil so far as any per- 
manent effect was concerned. 

It was then suggested that it might be possible to wash 
the gall-bladder free from organisms by the use of chola- 
gogues (inspissated ox gall, bile salts). The flow of bile is 
thus increased, it is true, and bacilli enter the intestinal 
canal in increased numbers, but it was found that even after 
the administration of 3 to 5 'grams of inspissated bile a day, 
continued for a period of three or four months, the bacilli 
did not disappear. It was noted their number diminished 
and that there were even periods during which they disap- 
peared, but in the end they always returned. That this 
should be so is, of course, not surprising, if we remember 
the anatomical relations of the gall-bladder to the common 
duct and the mechanical difficulties which stand in the way 
of any attempt to "wash out" the gall-bladder by means 
of the natural secretion of the liver. But even if this were 
possible we could not expect to "wash out" those organisms 
which in some manner have found their way into the ducts 
of the numerous glands and thus into the walls of the gall- 
bladder, and which would serve as a small but constant 
reserve. The problem hence resolves itself into the question 
of either killing the organisms in their stronghold by chemical 
or biological methods or of removing the stronghold itself. 
All attempts in the former direction have thus far led to 
nothing,* and I would particularly emphasize the uselessness 
of vaccines to this end. 

* Lentz 6 reports that during the administration of fortoin (forrnalinized 
cotoin) , given either by itself, but especially in combination with extract of 
Phytolacca (laxative and cholagogue) and bicarboDate of soda (alkali) the 
elimination of bacilli diminished and even ceased for days at a time, and 
he accordingly suggests that some formalin product may in the end be shown 
to produce the desired result. 



100 TYPHOID FEVER 

Whether or not anything can be done during the course of 
the disease to prevent the development of the carrier condi- 
tion seems doubtful at present, but in those cases in which 
infection of the urine has taken place, it would seem that 
much good can be accomplished by the administration of 
hexamethylenetetramin (urotropin) . 

Some writers, such as Semple and Greig, 44 however, claim 
that permanent sterilization of the urine cannot be accom- 
plished in this manner. It is to be noted, however, that at 
the time when this view was expressed the drug was given 
in very small doses. Crowe, 45 in 1917, emphasized its value 
in typhoid bacilluria and pointed out that providing large 
doses be given — at least 75 grams per diem — the drug appears 
in the gall-bladder even in a concentration which suffices 
to render the bile an unsuitable medium for the growth of 
bacteria. 

Surgical Treatment. — There remains then for consideration 
the question of surgical interference, and so far as the evi- 
dence goes this method is the only one that has thus far led 
to satisfactory results. In 1907 Dehler 35 reported two suc- 
cessful cholecystotomies in the case of chronic typhoid car- 
riers, occurring in an insane asylum under his charge.* In 
1912 he 35 referred to two additional cases with a similarly 
satisfactory outcome. In both active gall-bladder symptoms 
had existed, and in themselves warranted the operation irre- 
spective of the carrier condition. Subsequent investigations, 
however, have shown that such a favorable outcome does 
not always occur, and the later tendency has been to perform 
cholecystectomy rather than cholecystotomy. This seems 
more reasonable since we know that the bacilli are found not 
only in the contents of the gall-bladder, but in its walls as 
well. 

Quarantine and Control of Carriers. — But while operative 
treatment may be urged upon every fecal carrier, and may 
be accepted by those who actually suffer from gall-bladder 
symptoms, and even by some of those who are personally 
not inconvenienced by their condition, but wish to be cured 

* According to Frosch the result in these two cases was not a permanent 
one, 



THE MANAGEMENT OF TYPHOID CARRIERS 101 

from altruistic motives, it is clear that the vast majority of 
the cases will not come to operation of their own free will, 
nor can they be compelled to subject themselves to the 
dangers incidental to such treatment. The problem then is 
manifestly to subject the chronic carrier to such supervision 
and regulation as to render him as little dangerous to others 
as possible. To this end it is essential that no case of typhoid 
fever, and the same is true of paratyphoid, should be dis- 
charged from medical supervision until his status in reference 
to the carrier condition has been determined by the proper 
authorities. It has accordingly been suggested that every 
typhoid convalescent be regarded as a carrier until five suc- 
cessive examinations of both urine and feces, at intervals of 
three days, have given negative results, and until any other 
focus of infection that has developed in the course of the 
malady (discharging sinuses, otitis media) has been cured or 
shown to be free from typhoid bacilli. This work should be 
under the direct supervision of the health department, but 
could be carried on very well, in the case of hospital patients, 
by the department of clinical pathology. Should the patient 
be discharged from the hospital while still in the carrier 
stage, proper notification should be made to the health 
department, which should then assume control. 

While the supervision of temporary carriers should offer 
relatively little difficulty, the problem of the chronic carrier is 
a very formidable one. As I have pointed out before, there is 
reason to believe that in a city of the size of New York there 
may be 25,000 carriers, and to prevent any one of these from 
conveying the infection to others would indeed be a colossal 
undertaking. It is a problem which nevertheless seems capable 
of partial solution at any rate, if we bear in mind that the 
typhoid carrier is dangerous to others largely through his 
contact with foodstuffs. Evidently those carriers are the 
most dangerous who are themselves unaware of their condi- 
tion, and the manifest duty of the authorities is to explain 
this danger to such people. A great deal of valuable cooper- 
ation could, no doubt, be secured in this manner, which in 
itself would bring about an improvement. It is clear, how- 
ever, that without a certain degree of police regulation on 



102 TYPHOID FEVER 

the part of the health department, education of the carriers 
alone would not produce the desired result. Regulation is 
evidently the sine qua non of public safety. To this end 
all carriers should be registered as soon as their condition has 
been recognized and the authorities notified of any change of 
address or of occupation. This should be verified from time 
to time and the records thus kept up to date. Next in order 
should come such legislation as would bar every carrier from 
engaging in any occupation which would bring the individual 
into contact with public food supplies. The most superficial 
study of the problem shows that in the majority of cases 
of typhoid fever which have been traced to carriers the latter 
were found to be engaged in some branch of the dairy busi- 
ness or as cooks. Such legislation could be supplemented by 
the demand that no individual engaged in the handling of 
public foodstuffs be permitted to engage help without a 
permit from the health authorities stating that the individual 
is not a carrier. Still further legislation would, of course, 
suggest itself as desirable, but ordinances covering the three 
points just considered, if enforced, would go far to eradicate 
typhoid fever from those cities and towns, at any rate, in 
which an adequate sewerage system and a safe drinking water 
supply already exist. Where this is not the case the danger 
from the carrier is, of course, proportionately greater, and 
in handling the situation it would appear simpler to eliminate 
the existing deficiencies than to attempt to regulate the dis- 
infection of the carriers' discharges which would be the only 
alternative. 

In country districts, in which wells represent the only 
supply of drinking water and in which the backyard privy 
is only too often unpleasantly close to the former, the 
menace of the carrier is indeed great, and becomes even more 
formidable when, as frequently found, the food supplies and 
the household dairy are, of necessity, in the hands of the same 
individual, who herself more than likely is unaware of her 
fatal gift. Education coupled with 'prophylactic vaccination 
of all those who are thrown in contact with the carrier will 
here, no doubt, accomplish a great deal of good. The sine 
qua non, of course, is here also the recognition of the carrier, 



PARATYPHOID FEVER 103 

and to this end we require the cooperation of the attending 
physician and the local health officer. Without such assis- 
tance no progress can be made, and in its absence we shall 
only too often find the disease dragging on in a community 
for years and years, until the majority of the individuals 
who have been thrown in contact with the carrier have finally 
acquired an immunity through an attack of the malady. 

In fine, it should be borne in mind that while vaccination 
does not rid the carrier of his organisms, the number of 
would-be-carriers will be diminished in direct ratio to the 
extent to which vaccination of all those who in any way 
may be subjected to the possibility of becoming infected, is 
practiced. In other words, there is a theoretical possibility 
of stamping out typhoid fever through universal vaccination, 
irrespective of the problem presented by the typhoid carrier. 
This has been well shown in the course of the present war, 
where typhoid fever is as uncommon as formerly it was one 
of the principal scourges of military camps. 

PARATYPHOID FEVER. 

While we have less specific information relating to the role 
of carriers in the dissemination of paratyphoid fever than in 
connection with typhoid fever, there is sufficient evidence 
to show that this is practically the same, in so far at least as 
infection with the paratyphoid B bacillus is concerned. Here 
also the organism has been found to invade the gall-bladder; 
here also does it appear in the feces, not only during the active 
stage of the malady, but in a certain percentage of cases also 
during convalescence. Passive carriers of the organism fur- 
ther are known to occur, and in certain districts are indeed 
so common, that it is exceptional to meet with individuals 
who are not carriers; and that the disease may assume epi- 
demic proportions has been abundantly demonstrated — as 
with us during the recent concentration of our army on the 
Mexican border. 

For practical purposes, therefore, it is unnecessary to con- 
sider paratyphoid carriers separately from typhoid carriers. 
Their import, their recognition and management are essen- 



104 TYPHOID FEVER 

tially those of the latter, and have been in a large measure 
considered under that heading, so that a recapitulation at 
this place is scarcely necessary. 

BIBLIOGRAPHY. 

1. Koch, B.: Veroffentl. a. d. Geb. d. Mil. Sanitatswesens, 1903, H. 21. 

2. Neufeld: See resume under heading '.'Typhus" in Kolle-Wasser- 
mann's Handbuch d. pathogenen Migroorganismen, vol. ii. 

3. Frosch: Begionare Typhusimmunitat, Festsch. z. 60 Geburtstag 
v. B. Koch, Jena, 1903. 

4. v. Drigalski: Centralbl. f. Bakt,, 1904, vol. xxxvi, H. 5. 

5. Donitz, W. : TJeber d. Quellen d. Ansteckung mit Typhus, Koch 
Festsch., 1903, p. 297. 

6. Lentz: Ueber chronische Typhusbazillentrager, Klin. Jahrb., 1905, 
vol. xiv, p. 475. 

7. v. Drigalski: Ueber Ergebnisse b. d. Bekampfung d. Typhus nach 
Koch. 

8. Frosch, P.: Die Verbreitung des Typhus durch sogenannte Dauer- 
ausscheider und Bazillentrager, Klin. Jahrb., 1908, vol. xix, p. 437. 

9. Forster, J.: Ueber d. Beziehungen d. Typhus u. Paratyphus z. d. 
Gallenwegen, Munchen. med. Wchnschr., 1908, vol. lv, p. 1. 

10. Levy u. Weber: Zentralbl. f. Bakt,, 1907, vol. xliii, p. 419. 

11. Blumenthal: Ueber d. Vorkommen v. Typhus u. Paratyphus- 
bazillen b. Erkrankungen d. Gallenwege, Munchen. med. Wchnschr., 1904, 
No. 37. 

12. Fornet: Munchen. med. Wchnschr., 1906, No. 38. 

13. Kayser: Ueber d. Gefahrlichkeit d. Typhusbazillentrager, Arb. aus 
d. K. Gesundheitsamt, 1906, vol. xxiv, p. 173, and ibid., 1907, vol. xxv, p. 223. 

14. Klinger, P.: Ueber Typhusbazillentrager, Arb. aus. d. K. Gesund- 
heitsamte, 1906, vol. xxiv, p. 90, and ibid., 1907, vol. xxv, p. 214. 

15. Minelli: Ueber Typhusbazillentrager u. ihr Vorkommerj unter 
gesunden Menschen, Zentralbl. f. Bakt., 1906, vol. xli, p. 406. 

16. Brion u. Kayser: Neuere klin.-bakter. Erfahrungen b. Typhus u. 
Paratyphus, Deutsch. Arch. f. klin. Med., 1906, vol. lxxxv, p. 525. 

17. Park, W. H.: Typhoid Bacilli Carriers, Jour. Am. Med. Assn., 1908, 
vol. Ii, p. 981. 

18. Brown, T. B.: Cystitis Due to the Typhoid Bacillus, Med. Rec., 
March 10, 1900. 

19. Young, H. H.: Cystitis Due to the Bacillus Typhosus, Maryland 
Med. Jour., November, 1901, p. 456. 

20. Jtirgens: Zeit. f. klin. Med., 1904, vol. xlii, p. 44. 

21. Anton and Futterer: Munchen. med. Wchnschr., 1888, No. 29. 

22. Chiari: Prager med. Wchnschr., 1893. 

23. Chiari and Krauss: Ztschr. f. Heilkunde, vol. xviii, H. 5. and 6. 

24. Kanthack: Baumgarten's Jahresber., 1897. 

25. Blachstein and Welch: Johns Hopkins Hosp. Bull., 1899, vol. i. 

26. Doerr, R. : Experimentelle Untersuchungen uber d. Fortwuchern v. 
Typhus Bazillen in d. Gallenblase, Centralbl. f. Bakt., 1905, vol. xxxix, p. 624; 
see also Wien. klin. Wchnschr., 1906, No. 34. 

27. Chiari: Abst. in Deutsch. med. Wchnschr., 1907, vol. xxxiii, p. 1767. 

28. Levy and Kayser: Bakt, Befund b. d. Autopsie eines Typhus- 
bacillentriigers, Munchen. med. Wchnschr., 1906, No. 50. " 



BIBLIOGRAPHY 105 

29. Hammond, F. S.: A Typhoid Bacillus Carrier, Jour. Am. Med. Assn., 
1909, vol. lii, p. 48. 

30. Nieter and Liefmann: Munchen. med. Wchnschr., 1907, No. 33. 

31. Gould, C. W., and Quails, G. L.: A Study of the Convalescent Car- 
riers of Typhoid, Jour. Am. Med. Assn., 1912, vol. lviii, p. 542. 

32. Bindsell: Bakt. Befund b. einem chron. Typhusbazillentrager, 
Ztschr. f. Hyg. u. Infectionskr., 1913, vol. lxxiv, p. 369. 

33. Rosenheim: Deutsch. med. Wchnschr., 1906, No. 47, p. 1933. 

34. Richardson, quoted by Doerr: Ref. Baumgarten's Jahresber., 1899. 

35. Dehler, A.: Zur Behandlung d. Typhusbazillentrager, Munchen. 
med. Wchnschr., 1907, Nos. 16 and 43, and ibid., 1912, No. 16. 

36. Hilgermann, R. : Ueber Bazillentrager b. Typhus, Klin. Jahrb., 
1908, vol. xix, p. 463. 

37. Frosch: Die Verbreitung d. Typhus durch sogenannte "Dauer- 
ausscheider" und "Bazillentrager," Klin. Jahrb., 1908, vol. xix, p. 537. 

38. Chesley, Burns, Greene and Wade: Three Years' Experience in the 
Search for Typhoid Carriers in Minnesota, Jour. Am. Med. Assn., 1917, 
vol. lxviii, p. 1883. 

39. Park, W. H. : Pathogenic Microorganisms, 1908, p. 288, and Typhoid 
Fever in New York, Monthly Bulletin of the Dept. of Health of the City 
of New York, 1915, vcl. v, p. 103. 

40. Kossel, H.: Zur Verbreitung d. Typhus durch Bazillentrager, 
Deutsch. med. Wchnschr., 1907, vol. xxxiii, p. 1585. 

41. Bolduan, C, and Noble, W. C. : A Typhoid Bacillus Carrier of Forty- 
six Years' Standing and Large Outbreak of Milkborne Typhoid Fever, 
Traced to This Source, Jour. Am. Med. Assn., 1912, vol. lviii, p. 7. 

42. Sawyer, W. A.: A Typhoid Carrier on Shipboard, Jour. Am. Med. 
Assn., 1912, vol. lviii, p. 1336. 

43. Bigelow, E. B.: Jour. Am. Med. Assn., 1912, vol. lviii, p. 1339. 

44. Semple, D., and Greig, E. D. W. : Typhoid Carriers in India, 
Scientific Memoirs of the Medical and Sanitary Department of the Govern- 
ment of India, new series, No. 32, Calcutta, 1908. Cited in British Med. 
Jour., 1908, vol. ii, p. 834. 

45. Crowe, S. J. : Hexamethylene Tetramin in the Treatment of Systemic 
Infections, Bull. Johns Hopkins Hosp., 1912, vol. xxiii, No. 259. 

46. Ravenel, M. P. : History of a Typhoid Carrier, Jour. Am. Med. Assn., 
1914, vol. lxii, p. 2029. 



EPIDEMIC CEREBROSPINAL MENINGITIS. 

The recognition of the manner in which the dissemination 
of epidemic cerebrospinal meningitis takes place is largely due 
to the painstaking investigations of von Lingelsheim 1 during 
the epidemic which prevailed in upper Silesia during 1904 
and 1905, in the course of which he could show that the 
organism in question may be demonstrated in the naso- 
pharynx of practically every patient. A number of previous 
investigators, it is true, had claimed that the meningococcus 
may be found in the secretions of the nose, but barring the 
isolated observations of Kiefer 2 in 1896 and of Albrecht and 
Ghon 3 in 1901 it is doubtful whether any of the others had 
actually been dealing with the meningococcus. A superficial 
analysis of Lingelsheim' s initial series of 787 examinations of 
the nasal and pharyngeal secretions of meningitis cases shows 
that a positive result was obtained in only 182, i. e., 23.12 
per cent. But on classifying these cases in accordance with 
the distance from which the material was sent, the percentage 
of positive findings is increased to 33 per cent, in the case of 
those in which the examination could be conducted on the 
same day as the collection of the specimens. It is noteworthy 
furthermore that of the 130 positive results of this series 
(corresponding to 390 cases) 104 were obtained in patients 
whose illness had not yet extended beyond the fifth day, 
which gives a percentage of 66.6. Between the sixth and the 
tenth day the positive findings represented 24.56 per cent.; 
between the eleventh and the twentieth days 11.29 per cent., 
and later than this date 4.39 per cent. Including all positive 
findings, irrespective of their geographical origin, i. e., 182 
cases, 147, i. e., 80.07 per cent., had not passed beyond the 
fifth day of the disease. 

v. Lingelsheim further showed that great care is necessary 
in the collection of the specimen and that material from the 
anterior and middle nares always furnished a negative result. 



ACTIVE CARRIERS 107 

Eliminating such sources of error, in addition to those arising 
from delay in the examination, as well as all cases which had 
passed the fifth day of the disease, he finally obtained a series 
of 49 cases, in 46, i. e., in 93.8 per cent., of which the menin- 
gococcus could be isolated. 

These findings are, of course, of the greatest importance, 
for they indicate on the one hand, the habitat of the organisms 
from which a transference to other individuals can readily 
take place, and they have opened up avenues for the investi- 
gation of the broader epidemiological aspects of the malady 
which formerly were closed. 

Regarding the route by which the organism reaches the 
meninges there is some difference of opinion. Some observers 
believe that infection takes place directly through the lymph 
channels penetrating the cribriform plate of the ethmoid, 
while others have expressed the opinion that a general septi- 
cemia precedes the meningitis proper. However that may be, 
there can be no doubt that the nasopharynx is the portal of 
entry, and that the disease may be conveyed to others through 
the nasopharyngeal secretion in connection with the act of 
coughing, of sneezing or through the sputum spray during 
ordinary conversation. 

The question now arises whether the disease can be trans- 
mitted only during the active period of the malady, or 
whether the organisms may persist sufficiently long as to 
warrant the conclusion that there are convalescent menin- 
gitis carriers; and further, whether, as in the infections pre- 
viously considered there are healthy carriers, who without 
having developed the disease proper, have yet become 
infected through contact with patients or other carriers and 
are themselves capable of conveying the disease to others. 

Active Carriers. — It has already been pointed out that 
whereas the organism can be demonstrated in the naso- 
pharynx of practically every case during the first five days of 
the malady, the percentage of positive findings rapidly dimin- 
ishes thereafter, so that as in v. Lingelsheim's series, follow- 
ing the twentieth day the figure dropped to 4.39 per cent. 
V. Lingelsheim also mentions that, whereas in early cases the 
organisms were obtained in large numbers and in almost pure 



108 EPIDEMIC CEREBROSPINAL MENINGITIS 

culture, this picture changed after a few days, other organ- 
isms, notably the catarrhal micrococcus and pneumococci 
replacing the meningococcus. In a few series of abortive 
cases in which an abundant herpetic eruption represented 
the principal clinical symptom, the organisms already dis- 
appeared after twenty-four hours. Any growth that was 
obtained after the expiration of the third week of the disease 
was usually meager and developed only after forty-eight 
hours' incubation. When once the cultures had become 
negative they usually remained so. But occasionally there 
was an exception. In one of the cases (51) a positive result 
was thus obtained on March 23; on March 27 and 31, as well 
as on April 6 and 14, the cultures were negative, but positive 
again on April 18 and 25. In this case there had thus been a 
negative interval lasting approximately three weeks, which 
was followed by a return of the organisms. In another case 
(141) the malady began on February 26. The throat cultures 
were negative from March 9 to April 6, when a positive result 
was obtained for the first time. 

From v. Lingelsheim's table it is indeed impossible to draw 
any very definite conclusions regarding the frequency with 
which the organisms persist beyond the twenty-first day, as 
the number of examinations covering this point is too small. 
His own conclusion that 4.39 indicates the percentage of 
positive findings after the expiration of the third week may 
be correct, but it is scarcely warrantable on the basis of the 
limited number of consecutive examinations which he has 
reported in connection with individual cases. That the 
organisms may persist for a long period of time is clearly 
indicated by his findings in one case, in which isolated colonies 
could yet be obtained at the expiration of three months 
from the beginning of the malady. Such cases, however, are 
unquestionably rare, and practically speaking we may say 
that only a very small percentage of individuals who have 
presented the classical picture of meningitis harbor the organism 
long enough during convalescence to be classed as carriers. 

While the active meningitis patient may be dangerous to 
his immediate entourage, it is after all rare that he conveys the 
disease to others. Even if he could do so he would not be in a 



PASSIVE CARRIERS 109 

position to directly infect many people. He is after all sick 
in bed while the malady lasts, and by the time that he is 
again able to go out his organisms have usually disappeared. 
He nevertheless represents a very formidable menace to the 
community at large, through the readiness with which he 
is able to produce carriers among those with whom he is 
brought into contact, even though these do not necessarily 
or even usually develop the disease themselves. The danger 
lies in the fact that these passive carriers may in turn give 
rise to a new series of carriers and so on indefinitely. Since 
the liability to the development of the actual disease is after 
all relatively limited, it may happen that at the outset of an 
epidemic the number of active cases is quite small, but that 
a large number of passive carriers is being rapidly produced 
through which susceptible individuals are then promptly 
reached. 

Passive Carriers. — Regarding the liability to passive infec- 
tion, on the part of a patient's attendants, it is clear from the 
available data that this may be very considerable. As a result 
of his investigations v. Lingelsheim arrived at the conclusion 
that from 10 to 15 per cent, of a patient's entourage — com- 
prising attendants, members of the family and near friends 
— is transformed into carriers. This is evidently too con- 
servative an estimate, for other observers, as well as he him- 
self, subsequently obtained much higher values. He thus 
mentions in his collective report of 1908, that in connection 
with 6 cases, where he had occasion to make a careful study 
of the other members of the patient's families, he invariably 
found all of them infected. 4 Ostermann 5 reports positive 
findings in 17 individuals out of 24 who had come in contact 
with active cases. Dieudonne and Hasslauer 6 found nine 
roommates of a diseased soldier infected. Particularly 
instructive also are the findings of Bochalli. 7 This investi- 
gator examined an entire battalion of 485 soldiers, among 
whom a case of the disease had appeared, and discovered 42 
carriers. Of the sixteen roommates of the patient ten, i. e., 
62.5 per cent., were carriers. Thirteen additional carriers 
belonged to the patient's company. Flack, 17 on the other hand, 
in reporting on cerebrospinal fever in the London district 



110 EPIDEMIC CEREBROSPINAL MENINGITIS 

from December, 1915 to July, 1916, mentions that of 1629 
contacts of 60 cases of the disease, only 139, i. e., .8.53 per 
cent., were found to be carriers. 

From the available data it is very difficult to draw any 
definite conclusions regarding the ratio between the per- 
centage of patients and healthy carriers. This must of 
necessity vary considerably. In those cases in which there 
is much irritation of the upper respiratory tract leading to a 
great deal of coughing and hawking the chances for a wide 
dissemination of the organisms are, of course, much greater 
than otherwise. So much is certain in any event that for 
every patient there is a very considerable number of carriers 
who have developed in the proximity of the patient, and as 
they in turn can give rise to other carriers and these to still 
others, the total number existing at the height, or more likely 
during the ascending period of an epidemic must be very large. * 
Being healthy carriers, i. e., individuals who are unrestricted 
in their movements, the disease will naturally not remain 
local, but become disseminated over an unlimited territory, 
so long, at any rate, as proper quarantine regulations do not 
exist or cannot be enforced. In this manner the various 
epidemics of the disease are readily explained. The pandemic 
which started in Europe in 1904 and spread over the entire 
globe within the following five or six years has not died out 
yet, either in Europe or in our own country, and has recently 
become a grave menace in our military camps, necessitating 
most active and vigorous methods to prevent its assuming 
renewed epidemic proportions. As yet no official information 
is available to indicate the ratio between patients and carriers 
in our cantonments but so far as I have been able to learn 
the experience gathered thus far corresponds to that obtained 
by the earlier investigators referred to above. 

Duration of the Carrier Stage in Passive Carriers. — As 
regards the duration of the carrier stage in healthy indi- 
viduals, the available data show the following: In Bochalli's 
series of 29 carriers the organisms had disappeared at the 
expiration of seven days in 9, after two weeks in 12, and 

* Flack reports that of 275 non-contacts which he examined, 6, or 2.18 
per cent., gave a positive result, 



VIRULENCE OF THE ORGANISMS 111 

after three weeks in 6, while in 2 they remained for four 
weeks. The findings obtained by Flack in 185 carriers are 
shown in the following table: 





Contact 




Non-contact 






carriers. 


Per cent. 


carriers. 


Par cent 


Under 2 weeks . 


. 20 


16.12 


12 


19.67 


2 to 4 weeks . 


. 45 


36.29 


32 


52.46 


4 to 6 weeks . 


. 26 


20.97 


5 


8.19 


6 to 8 weeks . 


14 


11.29 


2 


3.28 


8 to 10 weeks . 


4 


3.23 


7 


11.48 


10 to 12 weeks . 


5 


4.03 






Over 12 weeks . 


. 10 


8.07 


3 


4.92 



It would thus appear that the duration is about the same 
in this type of carriers as in those who have passed through 
an attack of the disease. 

Virulence of the Organisms. — From the very common occur- 
rence of healthy meningococcus carriers during an epidemic 
of the disease it might be argued that the organisms which 
were regarded as meningogocci in the individuals in question 
were in reality no true meningococci, or possibly strains only 
of non-virulent character. There is nothing to support such 
a view, however, and all the facts are against such a possi- 
bility. It has thus been conclusively shown that in indi- 
viduals who have in no way been exposed to meningitis 
either directly or indirectly, as far as could be ascertained, 
meningococci are rarely demonstrable in either the throat or 
nose. That they should be found in isolated instances can, of 
course, not be surprising, if we bear in mind that the organism 
is not known to occur outside of the body of man, in nature, 
and that so long as the disease has not died out altogether in 
a given district, there must still remain a few persons in which 
the organisms persist. The rapid increase in the number of 
carriers as an epidemic develops, coupled with the relatively 
brief duration of the carrier stage, clearly suggests that their 
presence is not immaterial. Direct investigations further- 
more, and notably inoculations of monkeys, have shown con- 
clusively that there is no difference in the virulence of the 
organisms obtained from healthy carriers, as compared with 
those derived from actual cases of meningitis. And last but 
not least is the direct evidence connecting outbreaks of the 
disease in a community with the introduction of carriers 



112 EPIDEMIC CEREBROSPINAL MENINGITIS 

coming from infected districts. Concrete examples of such 
outbreaks are given below. 

Habitat of the Organisms. — As regards the manner in which 
an individual becomes a carrier and more particularly of the 
predisposing causes very little is known. The fact that the 
organism's resistance outside of the body is so very slight 
suggests, of course, that in the human nasopharynx it must 
find special conditions favoring its growth. Bearing in mind 
the common occurrence of catarrhal conditions associated 
with lymphatic involvement in civilized races more par- 
ticularly, one cannot help but think that the ready avail- 
ability of certain serum constituents which are poured out 
upon the surface and which collect in the various nooks and 
corners of the mucous membrane of the nasopharynx may 
prove to be the point of attraction. Some writers lay stress 
upon an increased secretion of mucus as a factor favoring the 
development of the organisms in the throat, but it seems 
more likely that the underlying inflammatory process with 
the resultant exudation of serum is the more important. 
Unfortunately no systematic bacteriological examinations 
of the lymphatic structures of the throat have thus far been 
made in carriers, but we may logically assume that the organ- 
isms do not develop to any special extent upon the exposed 
surfaces of the mucous membrane, but more likely in its depth, 
and particularly in the clefts of the larger lymphatic struc- 
tures, such as the pharyngeal and faucial tonsils. In actual 
cases of meningitis, both acute and chronic, in children as 
well as in adults, Westenhoeffer 8 invariably found a very 
considerable hypertrophy, hyperemia and hypersecretion of 
the pharyngeal tonsil, and both he and v. Lingelsheim, as 
well as Meyer, 9 could demonstrate the meningococcus directly 
in the secretion taken from the depth of the recesses. Meyer, 
moreover, found them in the peripheral portion of the pharyn- 
geal tonsil, while in the deeper parts they were lost. The 
faucial tonsils in contradistinction to the pharyngeal gland 
Westenhoeffer found less frequently involved. 

Similar conditions no doubt exist in the carriers, though 
in these the pharyngeal tonsil cannot play the prominent role 
which Westenhoeffer has assigned to this structure in cases 
of the actual disease. According to Trautmann the pharyn- 



HABITAT OF THE ORGANISMS 113 

geal tonsil usually disappears after the eighteenth year. In 
view of the fact that in adults the carrier state is decidedly 
common, whereas the malady itself has a special predilection 
for children in whom the gland is present, and whereas all 
adults contracting the disease showed the same hypertrophy 
as children, this observation would suggest that this struc- 
ture may play an important role as portal of entry when it 
is developed, but that it is not essential as a nidus for the 
development of the organisms in carriers. In the latter the 
remaining lymphatic structures and mucous glands no doubt 
serve as points of anchorage for the organisms. 

A careful study of the distribution of meningococci in the 
upper respiratory tract of carriers has been made by Herrold. 15 
This investigator examined 93 segregated men with the 
results presented in the following three tables: 

TABLE I. — THE INCIDENCE OF POSITIVE CULTURES OF MENIN- 
GOCOCCI FROM DIFFERENT SOURCES OF THE UPPER RE- 
SPIRATORY TRACT OF NINETY-THREE CARRIERS. 

Positive. 
Source of cultures. Number. Per cent. 

Nasopharynx 66 70.9 

Tonsils 29 31.2 

Anterior superior nares 16 17.2 

Sputum 12 12.9 

TABLE II. — SUMMARY OF RELATIONS OF POSITIVE CULTURES 

FROM ELSEWHERE THAN THE NASOPHARYNX. 

Number. 
Positive tonsil, negative nasal and sputum cultures ... 25 
Positive nasal, negative tonsil and sputum cultures . . .11 
Positive sputum, negative nasal and tonsil cultures ... 8 
Positive tonsil and nasal, negative sputum cultures ... 2 
Positive tonsil and sputum, negative nasal cultures ... 1 
Positive nasal and sputum, negative tonsil cultures ... 2 
Positive tonsil, nasal and sputum cultures 1 

TABLE III. — A COMPARISON OF THE PERSISTENCE OF THE 
CARRIER STATE ACCORDING TO THE DISTRIBUTION OF 

MENINGOCOCCI. 

Incidence of persistence 
Number in after six weeks. 
Type of carrier. each group. Number. Per cent. 

Positive nasopharynx and elsewhere . . 39 28 73 . 

Positive nasopharynx, negative elsewhere 27 17 63 . 

Negative nasopharynx, positive elsewhere 11 6 54.6 

Negative nasopharynx and elsewhere .16 3 18.8 
8 



114 EPIDEMIC CEREBROSPINAL MENINGITIS 

The results speak for themselves and warrant the con- 
clusion that cultures should be taken not only from the naso- 
pharynx but from the tonsils and anterior superior nares as well. 

Practically important, further, according to Westenhoeffer, 
is the fact that in children median otitis frequently, in fact 
invariably, develops, and that in this situation the organisms 
may possibly persist for some time in some of the conva- 
lescent carriers. 

Relative Insusceptibility to Meningitis. — The question why 
there should be such a discrepancy between the number of 
carriers and of cases of the actual disease may in part be 
explained upon the basis of the anatomical differences in the 
lymphatic structures of the nasopharynx just referred to. 
But it is also conceivable that the disparity is more apparent 
than real, and that adequate clinical and laboratory investiga- 
tion might show that many of the supposedly healthy carriers 
are in reality at the time not in a condition of absolute health, 
and that many of the "insignificant or minor" acute catar- 
rhal conditions which are observed in the course of an epi- 
demic of meningitis, as well as at other times, may in the 
former instance be due to infection with the meningococcus. 
As a matter of fact it is well known that during epidemics 
of the disease many of the patient's attendants and house- 
mates, many of whom we now know to be carriers, develop 
an acute pharyngitis, while abortive cases with actual menin- 
geal symptoms are common, the true nature of which under 
ordinary conditions would never have been recognized or 
even suspected. Viewed from this standpoint the occurrence 
of actual meningitis would merely represent a possible and 
more or less accidental incident in the course of a meningo- 
coccus infection, just as certain cases of lobar pneumonia can 
only be regarded as a more or less accidental occurrence in the 
course of a corresponding pneumococcus infection. In both 
types of infection the clinical picture may, on the one hand, 
be that of a. simple pharyngitis, while on the other abortive 
lung, sc. meningeal symptoms may appear, and in yet others 
the orthodox symptoms of a malignant pneumonia or menin- 
gitis control the situation. Bat just as the milder pneumo- 
coccus infections are more common than the severer types, so 



RELATIVE INSUSCEPTIBILITY TO MENINGITIS 115 

is it conceivable that mild meningococcus infections may be 
more common than is generally supposed. 

However this may be, the carrier menace is the same, for 
from an epidemiological standpoint it would make very 
little difference whether a carrier is a healthy carrier or one 
convalescent from an infection so mild that it was not recog- 
nized, for the main danger in connection with the carrier is 
the individual's ignorance of his condition. 

To illustrate the relatively low susceptibility to menin- 
gitis, in adults at least, it may be mentioned that accord- 
ing to Medlar, 10 at Camp McClellan, the percentage of 
meningococcus carriers during the months of November 
and December, 1917, was between 3 and 6, but rose to 
from 12 to 20 in about 3000 cultures made, while the 
disease had in no sense assumed epidemic proportions, 
although there was an increase of the sporadic cases. In 
only one instance did more than one case of meningitis de- 
velop in a company, while the number of carriers was in 
some as high as forty. In this connection it is interesting 
to relate that synchronously with the increase in the number 
of carriers there developed an epidemic of sore throats. In at 
least half a dozen cases it was observed that men with severe 
pharyngitis showed on culture large numbers of meningo- 
cocci,* and that these disappeared when the pharyngitis 
cleared up. 

To what extent the individual carrier is a menace to others 
will, of course, depend very much upon circumstances, irre- 
spective of the number of organisms that he may harbor in 
his throat. Other things being equal the latter factor will, 
of course, be a very important one. But it stands to reason 
that an individual harboring the organisms only in small 
numbers may be more dangerous than another w 7 ho harbors 
many, if he be suffering from an irritative condition of the 
throat leading to much hawking and coughing, while the 
latter may be free from this and hence less liable to spray 
his surroundings. Then again much w T ill depend upon the 
susceptibility of the people with whom the carrier comes in 

* Two of these cases developed meningococcus meningitis a few days 
after their pharyngitis cleared up. 



116 EPIDEMIC CEREBROSPINAL MENINGITIS 

contact. If these be children or young adults and particu- 
larly if they come from a territory that has been free from 
meningitis the danger will be greater, even though the car- 
rier's throat be but lightly infected. For with virgin soil, of 
the most susceptible material, available for infection, only 
the proverbial spark will be necessary to initiate a most 
extensive conflagration. The mildly infected carrier, even 
though he himself infect perhaps but a single susceptible 
individual, may thus start a chain which will end only when 
suitable soil is no longer available. It is for this reason that 
the introduction of a carrier among a body of troops which 
has previously been free from the disease, and particularly 
of men who have been brought together from hitherto immune 
districts, is so liable to call forth an outbreak of epidemic 
proportions which may be most difficult to control. Con- 
versely it has been noted that the incidence of the disease 
in those military camps in which a systematic search for 
carriers is made and these are removed is smaller than in 
others where such precautions are not taken. 17 

Generally speaking, the more intimate the contact between 
the carrier and his victim, the greater the danger, and it is 
for this reason that a carrier mother will prove a particular 
menace to her children, and these in turn to each other. 
If we add to what we may call the normal danger arising 
from contact between carriers and the exposed the dangers 
incidental to living in close quarters, in badly lighted and 
ventilated rooms, especially during the winter and early spring 
seasons, with the resultant debilitating effects and the general 
tendency to " colds" and the resultant coughs, we may form 
a fairly clear idea of the consequences, particularly if, as I 
have said, the soil is virgin and the natural or acquired 
immunity negligible. 

While the majority of observers lay stress upon the dis- 
semination of the disease through infected particles of spu- 
tum, it should not be forgotten that freshly infected food 
material and infected dishes, napkins and the like, may pos- 
sibly play a role as well. Much additional work remains to 
be done in this connection, and in the meantime it will be 
well to err on the side of extra precaution. - 



EXAMPLES OF CARRIER ACTIVITY 117 

While the foregoing data leave no reasonable doubt that 
meningococcus meningitis is disseminated by carriers, it is 
rarely possible to connect individual carriers with indi- 
vidual patients bacteriologically, in such a manner as to 
definitely prove that infection took place through such and 
such a person and in no other way. Even when a carrier has 
been found in the household of a patient there still exists 
the possibility that the carrier was infected by the patient 
instead of vice versa. As only the occurrence of an actual 
case of the disease leads to an examination of the remaining 
members of a household we would rarely have previous knowl- 
edge of the bacteriological flora of the throats of the various 
people, and in the absence of such knowledge our chain of 
evidence would naturally be defective. Conditions here are 
very much the same as in a disease like cholera, where, as 
we have seen, the carrier may have left the locality which 
he has infected before the disease actually appears. A num- 
ber of suggestive cases, however, have been reported in the 
literature, and a few of these are here related. 

Examples of Carrier Activity. — An instructive situation has 
been reported by Flatten, 11 in which the evidence connecting 
the carrier w T ith the patient is perhaps as clear as can be 
demanded under the circumstances. 

At the time when the principal epidemic ravaging upper 
Silesia was centered at Konigshutte and its vicinity, a sec- 
ondary outbreak occurred in Vossowska and its surroundings, 
the relation of which latter points to each other, and the rail- 
road is shown in the accompanying diagram. At Vossowska 
are located two saw mills, two foundries and a chemical 
factory, and, as indicated in the diagram, it is a junction of 
two railroads. 

On March 15 and 16 two cases of meningitis developed 
among the children of two workmen of the chemical factory 
who resided at Klein- and Gross Stanisch, respectively — 
Anna W. and Albina Cz. In Anna's house there resided at 
the time a woman (X) who had visited relatives at Laura- 
hiitte, from February 9 to 18, and who could very readily 
have become a carrier there. She had attended the funeral 
of a child that had died from meningitis and had brought 



118 



EPIDEMIC CEREBROSPINAL MENINGITIS 



some of the clothing of the dead child with her. This she 
unpacked on March 14 or 15, i. e., about a month after her 
return, in the presence of Albina. 

Bearing in mind the low grade of vitality of the meningo- 
coccus, and particularly the fact that after remaining in the 




Fig. 1. 



dried state for only twenty-four hours the organisms are 
dead, we can eliminate the unpacking of these clothes as a 
causative factor of the outbreak of the disease. This is prac- 
tically ruled out, moreover, by the incubation period of the 
disease, which is very rarely shorter than 3 or 4 days. On 
the other hand we must remember that twenty-five days had 



EXAMPLES OF CARRIER ACTIVITY 119 

elapsed between this woman's return and the outbreak of the 
disease in Anna and Albina, and that she might very well 
have ceased to be a carrier at that time, but have given rise 
to another carrier. As a matter of fact, Flatten relates that 
meningococci were found in the nose of both Albina and the 
latter' s mother — in the case of the mother on March 20. 
It is thus quite conceivable that she may have been the car- 
rier who really infected Anna and Albina, while she in turn 
was infected by the woman X. 

On March 16 another case of meningitis developed, the 
victim being Johann Ko, the son of a workman in one of 
the foundries of Vossowska, and residing there. This man's 
stepdaughter had been associating with Albina's family. On 
March 24 Leopold K., a cousin of Albina, was taken ill. 
On March 26 followed the case of Albina's brother. 

On March 28 and 30 three children developed the disease 
in Mischline. Their father worked in one of the saw mills of 
Vossowska and was shown to be a meningococcus carrier; 
one brother worked in the chemical factory and a sister who 
was proved to be a carrier alongside of one Johanna T., 
who was herself a carrier. On March 30 two children of a 
widow living at Kolonowska were taken ill, and it is note- 
worthy that two workmen living in the same house were 
employed in the same mill as the meningococcus carrier, the 
father just referred to. Then followed two additional cases 
at Gross Stanisch, whose father had been working in close 
proximity to the house of Johann Ko. Later came still other 
cases which in turn could be connected with those mentioned 
above. As none of the relatives of the patient had been 
away from their houses or their places of work for weeks, 
the assumption would seem justifiable that the disease was 
introduced into the district by the woman X, who probably 
made a carrier of Albina's mother, and that from this focus 
still other carriers were produced through which the disease 
was ultimately conveyed to the various children mentioned. 

Another interesting outbreak has been related by Rieger. 12 
In this instance 19 cases developed between April 11 and 
May 11 among people who stand in some relation to a leather 
factory; 17 of these were children and 2 adults. Upon inves- 



120 EPIDEMIC CEREBROSPINAL MENINGITIS 

tigation it was ascertained that during the month of Feb- 
ruary already 4 cases had developed in the home of one of 
the workmen, St., of the leather factory, which was located 
in the village of Luisenthal, 5 km. distant from Brieg. Of 
these 4 cases 2 had died and 2 recovered, the true nature of 
the disease not having been recognized at the time. The 
husband had remained away from his work in the leather 
factory in order to help care for his family from February 24 
to April 2, returning on April 3. On April 11, the first case 
of meningitis then developed at Brieg among the children 
of the workmates of St. It is possible, of course, that St. 
was a carrier and gave rise to other carriers in the factory, 
who in turn infected their respective families. On the other 
hand, a second possibility suggests itself. During St.'s ab- 
sence three of his former workmates were taken ill with an 
inflammatory affection of the throat, accompanied by fever 
and the usual systemic symptoms, though without any signs 
of meningitis. The true nature of these cases was not ascer- 
tained, but on May 5 another workman was taken ill with the 
same symptoms and in his throat meningococci were demon- 
strated. It is thus possible that St. had nothing to do with 
the outbreak but that the disease was introduced by some 
other person with the production of carriers from that source. 
Regarding the possible manner in which the men were 
infected it is interesting to note that they all used the same 
drinking cup. The various patients were removed to a hos- 
pital, the common drinking cup replaced by fifteen separate 
cups and these disinfected after use, and the families of those 
who refused to go to a hospital were quarantined. The epi- 
demic seemed to have come to a stop, as no further cases 
developed immediately after May 11. But on May 23 an- 
other child, whose father was employed in the same factory, 
was taken ill. It was then found that the suspected carrier 
St. daily brought sausage to the factory and sold this to 
his workmates. When this was stopped and the basket had 
been destroyed no additional cases appeared. This, of course, 
again suggests that St. was the original carrier and that the 
throat infection of the three men referred to above was not 
meningococcic in origin. 



EXAMPLES OF CARRIER ACTIVITY 121 

In fine it may be mentioned that none of the nineteen 
children had been in the factory, that some of them lived in 
Brieg itself and some in nearby villages, and that the infec- 
tion must hence have taken place through the intervention 
of a healthy carrier. 

Minor local outbreaks such as these are really very instruc- 
tive, for they offer much better chances for discovering the 
manner in which they have been produced. In the first 
instance the chain of evidence seems quite satisfactory, and 
in the second sufficiently suggestive for all practical purposes, 
though one cannot help but wish that St.'s throat had been 
examined bacteriologically. Especially interesting in the 
second instance is the possibility that the drinking cup and 
the sausage may have served as vehicles in the dissemination 
of the organisms. The pernicious possibility of the first more 
particularly should ever suggest itself in the course of an 
investigation. 

Further, interesting cases have been reported by Flack, 17 
as follows : 

I. Sapper Bs. returned from France on April 9, 1916, and 
had been complaining of headache and pains in the back and 
legs while in the trenches a few days previously. There is no 
evidence that he had had any meningitis. Two days after his 
arrival one of his children was taken ill and removed to a 
general hospital with symptoms of cerebrospinal meningitis. 
Next day another child was taken ill and removed to an 
isolation hospital, where he died of the disease. The father 
was now isolated, and found to be a carrier of Type II 
meningococcus. A few days after removal, the first child was 
discharged after what was termed "an abortive attack" of 
cerebrospinal meningitis. He was brought by his sister on the 
Thursday. Up till then the sister had been quite well. She 
did not subsequently see her father at close quarters, but on 
the following Sunday she was taken ill in the morning and 
died within twenty-four hours. A swab from the child having 
the abortive attack showed the presence of the Type II 
meningococcus in the nasopharynx. 

There had been no cerebrospinal fever in the borough for 
eighteen months until these cases occurred. 



122 EPIDEMIC CEREBROSPINAL MENINGITIS 

II. Private P., A.S.C., returned from France on leave on 
July 18. On July 27 one of his children was taken ill and died 
the next day of cerebrospinal fever. A swab from P. gave a 
plate showing many colonies of meningococcus (Type IV). 
His other three children were subsequently removed to a 
fever hospital. One child was suffering from pyrexia, with a 
temperature of 101° F., but no marked meningitic symptoms. 
The cerebrospinal fluid showed no cocci or increased cell 
content. From the fluid of a swollen knee-joint, however, the 
meningococcus was grown (Type IV) . This appears to be an 
example of infection of the knee-joint without involvement of 
the meninges. A blood culture, taken one day after the knee 
had swollen, proved sterile. 

III. Case 54 developed the disease at H. Military Hos- 
pital after he had been in there for two months on account of 
an accident. Of the four positive contacts, three were of the 
same type as the case. Two of these were in the beds on each 
side of the case, and the other was the staff nurse of the ward. 
All the available evidence went to show that the nurse was a 
chronic carrier, and inquiry revealed the fact that she had 
started nursing in the ward within two months, and had been 
nursing several cases of meningitis a year before and had not 
been swabbed subsequently. It seems probable that the case 
was infected by this staff nurse. The two other positive 
contacts cleared up quickly; the nurse is still a carrier. 

The Recognition of Meningococcus Carriers. — The only way 
in which meningococcus carriers can be recognized is by a 
cultural analysis of the flora of the individuals' throats. A 
direct microscopical examination of the secretion is insuf- 
ficient, as neither the form of the organisms, nor their location 
in reference to cells, nor their behavior to staining by Gram 
is sufficiently characteristic as to enable one to state with 
any degree of precision that one is dealing with the meningo- 
coccus or not. It is indeed rare that one does not find some 
organisms even normally which morphologically do not 
appear suspicious. No doubt the element of experience plays 
a great role in such examinations, but until this has been 
gained so many wrong diagnoses will have been made that 
the harm already done can scarcely be balanced by the good 



RECOGNITION OF MENINGOCOCCUS CARRIERS 123 

accomplished later on. In the diagnosis of carriers of any 
kind, and particularly of such dangerous carriers as the types 
which we are now considering, the element of precision is all- 
important, and it is absolutely essential that no time be lost 
through uncertainty on the part of the observer. Particu- 
larly in times like the present, when an incorrect laboratory 
report may cause the most serious disorganization in our 
military camps and cantonments, only such methods should 
be employed as experience has shown to be reasonably 
reliable, even when used by observers of relatively little 
experience. To this end I can warmly recommend the cul- 
tural procedure suggested by Olitsky 13 which is essentially 
based upon the partial elimination of those organisms which 
are most apt to cause confusion, by agglutination with normal 
horse serum, and the final identification of the meningococcus 
through its agglutination by a corresponding antiserum of 
high titer. 

Olitsky's Method. — The initial steps of the method are 
those which have been in common use in the clinical labora- 
tory before, viz., the preparation of plates of dextrose-serum 
agar, 0.4 per cent, acid to phenolphthalein, which are smeared 
with the secretion obtained from the nasopharynx of the 
suspected individual, incubated overnight and then subjected 
to a primary examination, to ascertain roughly how many 
different types of organisms are present, and particularly 
which ones resemble the meningococcus sufficiently as to 
necessitate a further analysis. Some of these initial steps 
require a more detailed consideration. 

Preparation of the Medium. — So far as the preliminary 
medium is concerned, it should be remembered that ox blood 
cannot be used. The most convenient, because the most 
readily obtainable, is sheep serum. The sheep blood is col- 
lected at the slaughter house, allowed to clot and placed in 
the refrigerator until a sufficient quantity of serum has sepa- 
rated out. One volume of this is diluted with three volumes 
of distilled water and the mixture sterilized in an Arnold 
steam sterilizer by heating on three consecutive days for 
thirty minutes, or in the autoclave, at fifteen pounds' pres- 
sure, for forty minutes on a single occasion. This constitutes 



124 EPIDEMIC CEREBROSPINAL MENINGITIS 

Hiss's serum water, and is kept on hand in small flasks in 
appropriate amounts. 

The agar is made from beef or bob veal infusion in the 
usual manner. It' should be 0.4 per cent, acid to phenol- 
phthalein and contain 1 per cent, of dextrose, which is added 
just before sterilization. The agar is tubed in 10 c.c. lots and 
the plates prepared when needed by melting the agar, cooling 
it to 50° C., when it is poured into the plates and 2 c.c. of 
serum water are added for every 10 c.c. of agar. 

Slants of dextrose-serum-agar may be prepared in the same 
manner and can be kept on hand as such, provided that dry- 
ing of the surface is carefully guarded against. The plates, 
however, are really what we need for our special purpose, 
and should invariably be freshly prepared. 

Olitsky further recommends the use of 2 c.c. of a sterile 
10 per cent, litmus solution in distilled water for every plate 
of 10 to 12 c.c. of the serum-agar, with the view of aiding 
in the differentiation between the meningococcus and the 
catarrhal micrococcus, the colonies of the former assuming 
a pink hue, while those of the latter are blue. Flexner 14 
states that this addition does not constitute as great an 
improvement over the colorless agar as might be supposed, 
as the freshly isolated meningococcus only possesses weak 
power of fermenting glucose, on the one hand, while certain 
streptococcus colonies assume a pink hue and thus confuse 
the plate. He adds, however, that on this medium the 
colonies of Micrococcus flavus present an opaque yellow or 
greenish appearance which is readily distinguished. Accord- 
ingly one can follow one's own inclination, the main point 
being to familiarize oneself thoroughly at the outset with 
the picture obtained from throats that are free from the 
meningococcus. 

In the absence of sheep serum, horse serum to the extent 
of 2 per cent, may be substituted for the sheep serum water. 
Human ascitic fluid also furnishes excellent results, and 
Flexner warmly recommends defibrinated rabbit blood, of 
which 0.25 c.c, laked in 0.5 c.c. of sterile water, is placed in 
a plate, and there mixed with 10 c.c. of the melted glucose- 
agar, that has previously been cooled to 45° C. 



RECOGNITION OF MENINGOCOCCUS CARRIERS 125 

The latter method may prove useful when isolated exami- 
nations are to be made, but when large bodies of people are 
to be examined the sheep serum medium is the most practical. 

Inoculation of the Plates. — The plates, however they may 
have been prepared, are smeared with the secretion obtained 
from the individuals' nasopharynx. To obtain the latter it 
is most convenient to make use of the so-called West tube, 
which is pictured in the accompanying illustration : 



Fig. 2. — West swab tube. 

This is essentially a glass tube with thick walls, having 
an inside diameter of about 7 mm. and a length of about 
16.5 cm., being bent near the one end to nearly a right angle. 
Through this tube passes a copper wire to which a smooth 
cotton swab has been fastened. The latter is pulled back into 
the tube sufficiently so that this can be plugged with cotton. 
A similar plug is placed in the proximal end. Thus prepared 
the tubes are sterilized by dry heat and can then be kept on 
hand in any desired number, until they are needed. Before 
use the guard plugs are removed, the bent end passed behind 
the velum palati, when the swab is pushed out, turned from 
side to side and again withdrawn into the tube. A plate 
being ready at hand, the swab is pushed out again, and the 
surface gently stroked, any particles of mucus that may be 
visible with the naked eye being further teased out on the 
medium with a platinum or nichrome wire. After inocula- 
tion the plates, properly labeled, are placed in the incubator, 
or if the examination has been made at a distance from the 
laboratory, in a metal box, which in turn is set in a vessel 
containing warm water, and transported as rapidly as pos- 
sible. Under no circumstances should the swab be allowed 
to become dry before the inoculation, or the material or plate 
permitted to cool, for any length of time. Most failures at 
isolation of the meningococcus, when this is present, are due 
to oversight of these rules. It should further be remembered 



126 EPIDEMIC CEREBROSPINAL MENINGITIS 

that the meningococcus must be sought for in the naso- 
pharynx, and that swabbing of the anterior and middle 
nares, as well as of the oral fauces only, serves no useful 
purpose. As the organism may, however, also occur in the 
crypts of the tonsils these should likewise be examined, a 
small swab being introduced into the anterior crypt more 
particularly, as deeply as possible, and a separate plate 
secured from this source. 

Analysis of the Colonies Obtained on the Plates. — After 
incubating the plates at 37° C. for from sixteen to twenty 
hours (overnight), which may be followed by keeping them 
at room temperature for four to six hours further, during 
which time the colonies of the catarrhal micrococcus continue 
to increase in size and become opaque with sharply defined 
borders, the next step in the analysis of the plates constitutes 
Olitsky's method proper. This calls for 1 per cent, glucose 
broth — made from veal infusion — having an acidity of from 
0.5 to 0.7 per cent, to phenolphthalein, to which 5 per cent, 
of unheated, sterile, clear normal horse serum is added. 
The mixture is conveniently placed in small tubes (8 to 10 
mm. in diameter, with a length of 9 cm.) in 1 c.c. lots. 

Suspicious-looking colonies are now fished from the plates 
and transferred to this medium — a colony to a tube — and 
incubated for twelve hours or overnight, if more convenient. 
During this incubation certain organisms, which may be mis- 
taken for the meningococcus, grow in the medium in ques- 
tion, but being agglutinated at the same time leave the super- 
natant fluid clear or nearly clear. This group is termed the 
normal horse serum negatives and comprises the Micrococcus 
flavus, the Micrococcus crassus, the Micrococcus pharyngis 
siccus and an unclassified Gram-positive bacillus.* All such 
tubes, showing a clear supernatant fluid over the bacterial 
growth at the bottom, can be discarded at once. The remain- 
ing tubes in which the supernatant fluid is turbid may con- 
tain the meningococcus, the Gram-positive staphylococci, 
streptococci and the catarrhal micrococcus. After a little 
experience it will be possible to eliminate some of these also 

* The influenza bacillus does not grow in this medium, because it contains 
do hemoglobin. 



RECOGNITION OF MENINGOCOCCUS CARRIERS 127 

by direct inspection. The Micrococcus catarrhalis and the 
staphylococci grow with a dense turbidity and frequently 
show a pellicle on the surface. On shaking, the staphylo- 
cocci, as well as the streptococci, will show an agglutinated 
sediment, while in the case of the meningococcus this emul- 
sifies uniformly. The meningococcus tubes, moreover, show 
only a slight turbidity which, coupled with the appearance of 
the sediment on shaking, will mark these tubes as suspicious. 
To any such there is now added 0.1 c.c. of a 1 to 10 dilution 
in .85 per cent, saline of a polyvalent antimeningococcus 
serum of high titer. The tubes are next placed in a water- 
bath — not incubator — at 37° to 38° C. for two hours longer, 
during which time only those containing meningococci will 
clear up while the organisms are firmly clumped. The 
remaining tubes remain as before. From the tubes which 
have thus been found to contain meningococci smears for 
microscopic purposes, to demonstrate their Gram-negative 
nature, and subcultures for whatever additional purposes, 
may then be prepared, if desired, but not as a matter of 
necessity. 

For rapid agglutination work, Krumwiede 16 recommends 
the macroscopic slide agglutination test, which is conducted 
as described in the section on Typhoid Fever. He made use 
of curative horse sera with normal horse serum as control. 
Each serum should previously be tested against as many 
strains as possible to ascertain in what dilution satisfactory 
results can be obtained. In his experience a 1 to 50 dilution 
gave in general unsatisfactory results, while in 1 to 25 
dilutions the clumps were lessened in size and some delay 
in reaction occurred — with some strains at any rate — but 
even so the results were, on the whole, fairly good. The best 
and most prompt agglutination, however, was gotten with 
dilutions of 1 to 10. Krumwiede (I. c.) further recommends 
the following as a subculture medium for testing out suspi- 
cious-looking colonies that have grown out on the initial 
plate: viz., a serum-water agar containing 1 per cent, of lac- 
tose, 1 per cent, of saccharose and 1 per cent, of Andrade's 
indicator, with the reaction set to this indicator. By the aid 
of this medium those mouth organisms can be excluded 



128 EPIDEMIC CEREBROSPINAL MENINGITIS 

which ferment one or both of these carbohydrates, and whose 
colonies accordingly will assume a pink or red tint, while 
the meningococcus colonies appear colorless. 

As I have said before, Olitsky's method is very convenient 
for all purposes, and especially when a large number of indi- 
viduals are to be examined in a short time. It leads to a 
definite result in fully a day less than any one of the pro- 
cedures previously in use. But it calls for a certain amount 
of previous experience notwithstanding, to which end the 
beginner should familiarize himself with the behavior in pure 
culture, as well as in artificial mixtures, of the various types 
of organisms that may be met with in the throat and nose, 
before taking up the study of concrete cases. 

The Management of the Meningococcus Carrier. — Medicinal 
Treatment. — Attempts to bring about the disappearance of 
the meningococci from the throat by local medicinal treat- 
ment have for the most part led to no satisfactory results. 
This corresponds to our experience with other types of car- 
riers in which the upper respiratory tract is involved, and is, 
after all, what one would expect. 

The best results have been obtained with chloramin-T, 
both by vaporization and by spraying. Gordon and Flack 17 
recommend an aqueous solution containing 2 per cent, of 
chloramin-T, a liter of which is steam-sprayed into a chamber 
of 750 cu. ft. capacity, in the course of from fifteen to twenty 
minutes, during which time the carrier remains in the room 
and inhales the disinfectant through the nose. One treatment 
is given a day. Of 14 individuals who were treated in this 
manner 11 are reported to have cleared up, the organisms 
in the majority of instances having disappeared by the ninth 
or tenth day. 

Similar results were obtained with zinc sulphate, using a 
1.2 per cent, aqueous solution. With heavily infected indi- 
viduals, however, the number of necessary treatments was 
much greater. 

- A simpler procedure has been recommended by Dunham 
and Dakin 18 as follows: 

1. The nose is cleared with salt solution or with 0.25 per 
cent, aqueous chloramin-T solution either by spraying or 



MANAGEMENT OF THE MENINGOCOCCUS CARRIER 129 

irrigation. The nose should be blown into a handkerchief 
between applications; and the chloramin-T solution should 
be used thoroughly as a gargle. 

2. When the increased flow of secretion from the nose has 
subsided, the oil solution of dichloramin-T (see below) is 
applied with an oil atomizer. The oil spray should be 
repeated at intervals so as to make at least four treatments 
daily about equally spaced from each other. The spraying 
should be thorough and the oil carried to all parts of the 
membrane accessible. The first few applications of the oil 
sometimes occasion sneezing, but tolerance is soon acquired 
and subsequent applications cause no inconvenience. 

3. The preparation of the dichloramin-T oil embraces 
three steps. First, the solvent eucalyptol (United States 
Pharmacopoeia) is chlorinated: 500 c.c. are treated with 15 
grams of potassium chlorate and 50 c.c. of concentrated 
hydrochloric acid for twelve hours or longer, and then well 
washed with water and with sodium carbonate solution. The 
water is drawn off and 15 grams of dry sodium carbonate 
are added to the oil and the whole is allowed to stand for 
twenty-four hours. The oil is filtered off, and dried with a 
little solid calcium chlorid, when it is ready for use. 

Secondly, paraffin oil is chlorinated: To 500 c.c. of com- 
mercial paraffin oil, 15 grams of potassium chlorate and 
50 c.c. of concentrated hydrochloric acid are added and the 
mixture is exposed to light, preferably sunlight, for several 
hours. It is then transferred to a separating funnel and 
washed successively with water, a solution of sodium car- 
bonate, and again with water. The opalescent oil is drawn 
off, solid calcium chloride added, in small quantity, and about 
5 grams of animal charcoal. On subsequently filtering 
through paper, a yellowish oil ready for use is obtained. 

The third step is the preparation of the oil solution of 
dichloramin-T for use in the spray. Two-tenths gram of 
the dichloramin-T is dissolved in 2 c.c. of the chlorinated 
eucalyptol without heating. When the solution is complete, 
8 c.c. of the chlorinated paraffin oil are added. After mixing, 
the solution is ready for use. The solution contains 2 per 
cent, of dichloramin-T. It is relatively unstable, and should 
9 



130 EPIDEMIC CEREBROSPINAL MENINGITIS 

be discarded as soon as a distinct precipitate makes its 
appearance. An opalescence or moderate cloudiness is not 
evidence of material deterioration. It is a safe rule not to 
use the completed solution for more than three or four days 
after its preparation. It should be protected from strong 
light and is best kept in a cool place. Where large quantities 
are needed, a stock 10 per cent, solution of dichloramin-T 
in eucalyptol may be prepared and kept on hand in a cool, 
dark place for dilution with the paraffin oil, as 1 to 4, as 
required. The eucalyptol solution will suffer little deteriora- 
tion in a month. 

With the use of this spray it has been found possible to 
render the nasopharynx sterile in a few hours so far as the 
common aerobic bacteria of those structures are concerned. 
Only a small number of tests were made on meningococcus 
carriers, but so far as one can judge the results appear 
promising. 

Quarantine. — Meanwhile the question practically resolves 
itself into two problems, viz., the possibility of preventing 
the development of passive carriers and the isolation of these 
when the condition has once arisen. The great difficulty in 
connection with the first problem is the fact that practically 
the entire entourage of a patient is apt to be already infected 
by the time that the diagnosis of meningitis is first made in 
the latter. That relatively simple precautionary measures 
would prevent the production of carriers is, however, well 
known, as is evidenced by the fact that in hospitals where 
such measures are employed the attendants upon meningitis 
cases rarely become carriers. It would accordingly be best 
to place all meningitis cases in a hospital and to quarantine 
the remaining members of the household until adequate 
bacteriological examinations have either proved that they 
are not carriers, or until the carrier condition is over. On 
paper this accordingly seems to be a very simple problem, 
and in connection with minor local outbreaks it may be a 
simple task- With major outbreaks, on the other hand, it 
is far from simple, and a problem which it may be admitted 
in advance has not yet been solved. Under any circum- 
stances it should be remembered that a local investigation 



MANAGEMENT OF THE MENINGOCOCCUS CARRIER 131 

for carriers does not answer the purpose. As I have said 
before, we may assume at once that the entourage is in the 
carrier stage already by the time that the nature of the 
malady is recognized in the patient. The question then is 
can we find out with whom these people have come into 
more intimate contact, since the carrier state has probably 
existed. If this number be small their examination and isola- 
tion would frequently still be possible and justifiable, but 
if it be large the problem is only too frequently beyond our 
control. Were we in the possession of a preventive treat- 
ment as in the case of smallpox, or even of typhoid fever, it 
is clear that the end would justify the enormous amount of 
work that would have to be done, and even so it might be 
argued that the investigation should be made and that the 
spread of the malady might yet be prevented, and in theory 
as well as in practice such might be the case. The manage- 
ment of every outbreak will have to be undertaken according 
to individual circumstances. The sine qua non of a success- 
ful campaign is, of course, the prompt reporting of all sus- 
picious cases by the attending physicians. I have no doubt 
at all that much harm is here often done, partly through 
ignorance and partly through overconfidence on the part of 
the practitioner. But this applies to all of the infectious 
diseases, and is a problem per se. If once the disease has 
obtained a proper start in a community it must be remem- 
bered that there will be on an average ten carriers to a patient, 
and as carriers beget carriers it will become manifestly impos- 
sible to find them all, let alone to quarantine them all. 

Public instruction and widespread bacteriological exami- 
nation will have to be our mainstay, and will help us more to 
overcome a difficult situation than any other method. Public 
instruction should, however, not be confined to occasional 
lectures, but, in times of danger, to daily instruction, no 
matter how brief, regarding those methods of precaution 
which can be applied to everyone. This means, first and fore- 
most, instruction regarding the manner in which the disease 
is spread and the necessary rules which follow. It means 
among other things that individuals must learn to restrain 
both sneezing and coughing; that irritative conditions call- 



132 EPIDEMIC CEREBROSPINAL MENINGITIS 

ing for either also call for medical treatment; that childrne 
are more susceptible than adults; that the common drink- 
ing cup and towel are an abomination; that coughing people 
should be excluded from the handling and preparing of food ; 
that a mask covering mouth and nose can be had for a few 
cents and probably represents the most effective single factor 
in preventing the spread of the disease among those who are 
obliged to come in contact with it; 19 and, in fine, that the 
individual who is wilfully or maliciously careless not only 
deserves confinement in quarantine, but should be so con- 
fined until he has learned wisdom or the danger is over. 

Release from Quarantine. — When once quarantined car- 
riers should not be released until at least three successive 
examinations, made at intervals of three days, have given a 
negative result. 

I am fully aware that these suggestions seem to call for the 
millennium, but I am also fully aware that none better can 
be offered. The problem under existing circumstances cannot 
be solved in civil communities. Fortunately the predisposi- 
tion to the disease is apparently much less marked than to 
the development of the carrier state, and even though a 
serious menace in our camps it is not likely to assume 
epidemic proportions there, which would be comparable to 
outbreaks in the civilian population, for the very reason that 
the most fertile soil for such an epidemic, viz., children, is 
here absent. In camps our mainstay must be an initial 
period of quarantine during which each individual is exam- 
ined in reference to the carrier problem, just as he is exam- 
ined physically; further, prompt bacteriological examination 
of every inflamed throat, whenever this may occur, isolation 
of all suspects and possibly prophylactic vaccination which 
may do much good and in any event can do no harm. As 
a treatment for carriers vaccination, of course, is perfectly 
senseless. 

BIBLIOGRAPHY. 

1. v. Lingelsheim, W. : Die bakteriologischen Arbeiten d. konigl. 
hygienischen Station zu Beuthen, etc., Klin. Jahrb., 1906, vol. xv, p. 373. 

2. Kiefer: Berlin, klin. Wch'nschr., 1896. 

3. Albrecht and Ghon: Wien. klin. Wchnschr., 1901. 



BIBLIOGRAPHY 133 

4. v. Lingelsheim, W. : Die Verbreitung d. ubertragbaren Genickstarre 
durch sogenannte Dauerausscheider und Bazillentrager, Klin. Jahbr., 1908, 
vol. xix, p. 519. 

5. Ostermann: Cited sub. 4, p. 520. 

6. Dieudonne and Hasslauer: Cited sub. 4, p. 520. 

7. Bochalli: Cited sub. 4, p. 520. 

8. Westenhoeffer, M.: Patholog.-anatom. Ergebnisse d. oberschlesischen 
Genickstarrepidemie von 1905, Klin. Jahrb., 1908, vol. xix, p. 657. 

9. Meyer, E. : Bericht iiber rhino-laryngologische Beobachtungen, b. d. 
Genickstarre, ibid., p. 637. 

10. Medlar, E. M.: Epidemic Cerebrospinal Meningitis at Camp 
McClellan, Jour. Am. Med. Assn., 1918, vol. lxx, p. 459. 

11 Flatten, H.: Die ubertragbare Genickstarre im Regierungsbezirk 
Oppeln, Klin. Jahrb., 1908, vol. xix, p. 211. 

12. Rieger: Die ubertragbare Genickstarre im Kreise Brieg im Jahre, 
1905, Klin. Jahrb., 1908, vol. xix, p. 321. 

13. Olitsky, P. K.: Rapid Method for Identification and Isolation of 
Meningococci from the Nasopharynx, Jour. Am. Med. Assn., 1918, vol. lxx, 
p. 153. 

14. Flexner, S.: Mode of Infection. Means of Prevention and Specific 
Treatment of Epidemic Meningitis, ibid., 1917, vol. lxix, p. 641. 

15. Herrold, R. D.: The Distribution of Meningococci in the Upper 
Respiratory Tract of Carriers, ibid, 1918, vol. lxx, p. 83. 

16. Krumwiede, C, Jr.: The Possible Application of the Macroscopic 
Slide Agglutination in the Search for Meningococcus Carriers, ibid., 1917, 
vol. lxix, p. 359. 

17. Flack, M., and Gordon, M. H.: Bacteriological Studies in the 
Pathology and Preventive Control of Cerebrospinal Fever among the British 
Forces 1915 and 1916, Publ. by the Medical Research Committee, London, 
Special Report Series, 1917, No. 3. 

18. Dunham, E. K., and Dakin, H. D.: British Med. Jour., 1917, vol. i, 
p. 682. 

19. Weaver, G. H. : The Value of the Face Mask, etc., in the Prevention 
of Diphtheria, Meningitis, Pneumonia, etc., Jour. Am. Med. Assn., 1918, 
vol. lxx, p. 76. 



BACILLARY DYSENTERY. 

The question whether or not bacillary dysentery may be 
disseminated through the agency of human carriers of the 
type that we are considering in the present volume, i. e., 
of individuals who are themselves healthy and well, or at 
least not afflicted with the corresponding disease at the time, 
may be answered in the affirmative, though it must be 
admitted that it is probably very rare that the malady is 
spread in this manner. 

Active Carriers. — It is now well known that bacilli of the 
dysentery group are particularly numerous in the intestinal 
contents during the initial period of the malady, when indeed 
they may be present in almost pure culture. That patients 
during this stage of the disease are very dangerous goes, of 
course, without saying. Subsequently, however, the number 
of the organisms rapidly diminishes, and during convales- 
cence it is often very difficult to demonstrate their presence 
at all. That they may persist, however, for a variable length 
of time after the acute symptoms have disappeared has been 
shown by several investigators. Conradi 1 thus reports that 
in his experience the organisms continued to appear in the 
feces of practically every dysentery patient for at least a 
week or two after the clinical symptoms of the disease had 
subsided. He examined some 50 cases during the period 
of convalescence, and could demonstrate them in 27 as 
follows: in 11 mild cases from about the middle to the end 
of the second week of the disease, in 5 mild cases and 6 
moderately severe cases during the third week; and in 1 
mild case and 4 moderately severe cases at the beginning 
of the fourth week of the malady. In all these cases the 
stools still contained small particles of mucus, and it was in 
these that the organisms were found. Conradi mentions, 
however, that in some individuals he encountered them also 



ACTIVE CARRIERS 135 

in feces that were apparently normal in every respect between 
the second and fourth week of the disease. 

PfuhP reports having found the bacilli four weeks after 
the appearance of the initial symptoms in persons who had 
■been suffering from a severe type of the disease and at a time 
when the stools were yet abnormal to a greater or lesser 
extent. Lentz 3 found them in 3 out of 11 cases of so-called 
pseudodysentery* four or five weeks following "complete 
clinical recovery." An interesting instance has further been 
reported by Kruse, 4 where bacilli were found in the stool 
eight months after an attack of pseudodysentery, during 
which time the individual had apparently been in perfect 
health. Kruse in commenting upon this case remarks that 
the person's health had in reality only been apparently 
normal, since the stools still contained mucus. How frequent 
such cases of long-continued elimination of dysentery bacilli 
are is not known. Kruse states that while no other instances 
had been recorded in the literature up to that time (1908) 
he believes that they cannot be so very rare, as his own case 
was met with in the course of a study of only about two dozen 
persons. 

The number of bacilli which may be found in the feces of 
carriers of this type is probably always very small, and it 
usually requires a great deal of patience to demonstrate their 
presence at all. The elimination, moreover, may be inter- 
mittent, so that conclusions regarding their presence or 
absence should not be drawn from single examinations. 

So far as the danger is concerned which such carriers 
represent, it is thought that this is but slight, for the reason 
that the number of organisms in the feces is so small. Kruse 
indeed thinks that as a menace to the health of others they 
are a negligible factor, so long as the carriers themselves 
do not develop relapses. But as this probability seems ever 
to be present, so long as the carrier state lasts, they after all 

* The pseudo-group, so-called, comprises a group of organisms which 
differ from the Shiga-Kruse type in their agglutinative reactions, and unlike 
this type ferment mannite. This group comprises the B. dysenteriae Flexner, 
the Y bacillus of Hiss and Russell, Spronck's bacillus and others. Like the 
Kruse-Shiga type they are also pathogenic and produce the clinical picture 
of dysentery. 



136 BACILLARY DYSENTERY 

represent a potential danger of no small degree. It is thus 
interesting to note that at Poughkeepsie, where the disease 
had been epidemic during the summers of 1916 and 1917, 
new cases again appeared during the summer of 1918. It was 
then ascertained that in each case the patient was a member 
of a family in which the disease had occurred during the pre- 
ceding summer, and that two persons at least who were ill 
with the disease at that time were carriers.* 

Passive Carriers. — As regards the question whether passive 
dysentery carriers also exist, viz., persons who harbor the 
corresponding organisms in their intestinal contents, without 
having themselves passed through an attack of the malady, 
it would seem that such is also the case, although it must 
be admitted that this conclusion is based on a very small 
number of observations. Kruse 4 himself, it is true, states 
that in the course of his own investigations which extended 
over a period of seven years, he was never able to demonstrate 
the presence either of true dysentery or so-called pseudo- 
dysentery bacilli in the feces of healthy individuals, or of 
persons who were suffering from maladies other thau dysen- 
tery. Ford, 5 on the other hand, claims to have found pseudo- 
dysentery bacilli in the intestinal contents of 10 out of 50 
individuals who had died from various causes, but who 
had given no history of dysentery. But unfortunately he 
makes no statement regarding their serological reactions. 

On the other hand, Duval, 6 Jehle and Charleton, 7 as well 
as Conradi, 1 have reported positive findings in a small num- 
ber of children who had neither suffered from dysentery in 
the past nor were ill at the time of the examination. In 
Conradi's cases there was a definite history of contact with 
dysentery patients. Duval merely states that he could 
demonstrate the presence of pseudodysentery bacilli iti small 
numbers in the stools of two healthy children, in whom the 
movements had been produced with the aid of a mild laxa- 
tive. Unfortunately he does not mention how many indi- 
viduals he examined. Jehle and Charleton likewise found 
pseudodysentery bacilli in two healthy children, while in 

* Jour. Am. Med. Assn., 1918, vol. lxxi, p. 480. 



RECOGNITION OF DYSENTERY. CARRIERS 137 

many others negative findings were obtained. In all these 
cases the organisms were satisfactorily identified, so that 
there can be no question of the actual existence of carriers 
of this order. Nothing, however, is known regarding their 
number, and we can only say that while there is as yet 
no evidence that such carriers have initiated or extended an 
outbreak of the disease, this possibility exists at least in 
theory, and must be reckoned with in future studies of the 
epidemiology of the malady. 

Manner of Inf ection.— As to the manner in which the disease 
could be disseminated by carriers we may imagine that this 
would probably occur as in the case of typhoid fever, viz., 
through contamination of foodstuffs and of drinking water. 
That infection may occur through a direct transference from 
the carrier to another person seems unlikely, in view of the 
small number of organisms that are usually eliminated. It 
would appear more probable that an outbreak of the malady 
itself would result if the organisms were first to find their 
way into a medium in which they could multiply, and 
which would then be used as food. Actual observations of 
this kind have, however, not yet been made, but the possi- 
bility is suggested not only on theoretical grounds, but also 
by the findings of Zinsser 8 who could indirectly trace to the 
milk a small epidemic occurring in a hospital in New York 
City. 

The Recognition of Dysentery Carriers. — Technic. — For the 
purpose of isolating the dysentery bacillus from the stools 
of carriers it is well to search for particles of mucus, and, if 
present, to transfer such to tubes containing approximately 
5 c.c. of bouillon, in which adherent organisms are then emul- 
sified by shaking. Otherwise one is obliged to start with the 
fecal matter itself, and to prepare an emulsion of this by 
rubbing up a bit, the size of a split pea, in about 10 c.c. of 
broth. In either case the search is then continued as 
described in the section on typhoid carriers, the Endo medium 
being well suited for plating purposes (which see). It is 
better, however, instead of making the reaction 0.2 per cent, 
acid to phenolphthalein, to have it just neutral, or at most 
very faintly alkaline. After incubating for twenty-four 



138 



BACILLARY DYSENTERY 



hours the streaked plates are then examined. The dysentery 
colonies closely resemble those of the typhoid bacillus, 
and like these appear colorless, while the colon colonies are 
pinkish or red. Suspected colonies are now fished and 
subjected to a preliminary agglutination test, using a poly- 
valent antidysentery serum of high titer in a dilution of 1 
to 100, as described (see p. 93). If a positive or a suggestive 
reaction is obtained, the organism is subjected to further 
study by cultural and serological methods, in order to deter- 
mine the individual group to which the organism in question 
belongs. To this end the use of Hiss's carbohydrate serum 
water media* has been warmly recommended. The behavior 
of the different types is shown in the following table: 



Group I 



Group II 



f Shiga type 
i Kruse 



New Haven 

"Y" (His and 

Russell type) 
Seal Harbor 
Diamond 
Ferra 



Group III Strong type 

{ Harris — Flexner type 

I Baltimore 
Woilstein 



Ferment dextrose only with acid 
production, but without gas formation ; 
lactose, mannite, maltose, saccharose 
and dextrin are not affected. 

Ferment dextrose and mannite with 
acid production but without gas forma- 
tion ; lactose, saccharose and dextrin 
are not affected (maltose fermented 
after some days). 

Ferments dextrose, mannite and 
saccharose with acid production, but 
without gas formation; lactose, mal- 
tose and dextrin are not affected. 

Ferment dextrose, mannite, maltose, 
saccharose and dextrin, with acid for- 
mation, but without gas production 
(saccharose usually fermented only 
after six days) ; lactose not affected. 



More recent investigations have shown, however, that 
valuable as the carbohydrate method of classifying these 
various types has unquestionably been, it cannot be relied 
upon to the exclusion of serological methods. Thjotta 8 thus 
has pointed out that the behavior both to maltose and saccha- 
rose may differ from one experiment to the other, that a 
different result may be obtained with solid and liquid media, 
with old and young strains of bacilli, etc. 

The agglutinative behavior of the different groups toward 



* The preparation of these media has been described on page 198. 



MANAGEMENT OF DYSENTERY CARRIERS 139 

their corresponding antisera is shown in the following table, 
the figures having reference to the degree of dilution in which 
positive reactions could be obtained. 

Anti-group I serum. Anti-group II serum. Anti-group III serum. 

Group I . . 1 : 20,000 less than 1 : 100 less than 1 : 100 

Group II . . 1 : 200 1 : 6400 1 : 400 

Group III 

Group IV . . 1 : 800 1 : 1600 1 : 3200 



The agglutination test is carried out exactly as is usually 
done in the diagnosis of typhoid fever, the macroscopic slide 
agglutination method being used for purposes of orientation, 
and then followed either by the macroscopic test in various 
dilutions, in little tubes, or by the microscopic method, as 
one prefers, the former being the more convenient when large 
numbers of specimens are to be examined. 

Management of Dysentery Carriers. — As regards the manage- 
ment of dysentery carriers practically the same regulations 
should apply as in the case of typhoid carriers, bearing in 
mind, however, that negative bacteriological findings in con- 
valescents are of less significance than in connection with 
typhoid, for the reason that the organisms are much more 
apt to escape detection after the acute phase of the disease 
has been passed. For this reason it may be the safer plan to 
regard every dysentery convalescent as a potential carrier, 
irrespective of the bacteriological findings, so long as his 
stools are not free from mucus. Such individuals should be 
instructed regarding their possible danger to others; they 
should be excluded from participation in the handling of the 
food supply of communities as well as of families, and care 
should be had that their discharges do not contaminate the 
water supply. Actual quarantine will probably be necessary 
only very rarely. 

In fine, it should be borne in mind that every dysentery 
patient is a potential focus for the infection of others, irre- 
spective of the question whether these develop the disease 
themselves or merely become carriers. For this reason all 
those measures should be employed in safeguarding the 
patient's entourage which are used in connection with 



140 BACILLARY DYSENTERY 

typhoid, viz., screening, disinfection of stools, bed- and 
body-linen, the separate use of eating and drinking utensils, 
as well as their sterilization, and cleanliness on the part of 
the attendants. That notification of the health authorities 
should be practised and that these in turn should properly 
instruct the patient's family, goes, of course, without saying. 

BIBLIOGRAPHY. 

1. Conradi: Cited by Kruse. 

2. Pfuhl, E. : Cited by Kruse. 

3. Lentz: Kolle-Wassermann's Handbuch d. pathogenen Mikroorgan- 
ismen, 1903, vol. ii. 

4. Kruse, W. : Die Verbreitung der Ruhr durch sogenannte Dauer- 
ausscheider u. Bazillentrager, Klin. Jahrb., 1908, vol. xix, p. 529. 

5. Ford: Classification and Distribution of Intestinal Bacteria in Man, 
Studies from the Royal Victoria Hospital, Montreal, 1903, vol. i, No. 5. 

6. Duval, C. W., and Bassett, V. H.: The Etiology of Summer Diarrhea 
in Infants. Studies' from the Rockefeller Institute, 1904, p. 7. See also 
Wollstein, M.: The Dysentery Bacillus in Relation to the Normal Intestines 
of Infants, ibid., p. 193. 

7. Jehle and Charleton: Cited by Kruse. 

8. Zinsser, H.: Proceed. New York Path. Soc, 1907. 

9. Thjotta, T.: Om Dysenterii Norge, Med. Rev. Bergen, 1917, vol. xxxiv 
(cited in Abstracts of Bacteriology 1918, vol. ii, p. 23). 



ACUTE POLIOMYELITIS. 

The recognition of the fact that so-called acute anterior 
poliomyelitis is an infectious disease is of comparatively 
recent date and intimately connected with the discovery 
that the paralytic symptoms which in the past had been 
regarded as the essential feature of the disease in reality only 
represent an inconstant phase: that, in fact, there are many 
cases in which paralysis never occurs. The first observer 
to call attention to this possibility was Caverley, 1 who in his 
report on the Rutland epidemic of 1894 states specifically 
that 6 cases had no paralysis, but showed the same group of 
symptoms as were noted during the initial stage of those who 
subsequently did become paralyzed, viz., "headache, fever, 
convulsions or nausea, one or all." 

The significance of these abortive cases, however, was 
not recognized until Wickman, 2 in 1905, emphasized their 
occurrence and established their role in the dissemination of 
the disease beyond any reasonable doubt in so far as this 
was possible at a time when the causative agent of the malady 
and the possibility of its transmission to laboratory animals 
had not yet been discovered. These links in the evidence 
which were necessary to ultimately prove the infectious 
nature of the disease have since been supplied. In 1908 the 
malady was thus experimentally produced in monkeys by 
Landsteiner and Popper, 3 and shortly after by Knoepfel- 
macher 4 abroad, and by Flexner and Lewis 5 and by Strauss 
and Huntoon 6 in the United States. Its transference from 
one animal to another was achieved almost immediately 
thereafter by Flexner and Lewis 7 in New York, Leiner and 
Wiesner 8 in Vienna, and Landsteiner and Levaditi 9 in Paris. 
As regards the nature of the organism in question, Land- 
steiner and Levaditi, 10 as well as Flexner and Lewis, 11 then 
showed that it is not a bacterium but belongs to the group 
of the so-called filterable viruses. Its cultivation was 



142 ACUTE POLIOMYELITIS 

achieved by Flexner and Noguchi 12 in 1913, and typical 
lesions and death produced in monkeys with cultures that 
had been carried as far as the eighteenth generation. 

Laboratory investigation had thus fully substantiated 
the correctness of Wickman's assertion that acute anterior 
poliomyelitis is indeed an infectious disease, and the founda- 
tion had been laid for the further investigation of its epi- 
demiology by laboratory methods. This, however, has been 
attended with peculiar difficulties, for in so much as we are 
not yet in possession of any other method for the identifica- 
tion of the virus in question than the animal experiment, 
progress has of necessity been slow. But even so enough 
has been learned to warrant the conclusion that in the 
dissemination of this disease also human carriers play a 
dominant and possibly the only role. This view has been 
combated by a number of observers, and the hypothesis 
advanced that insects and notably the common house and 
stable fly act as distributors of the virus, 13 but it was shown 
that while these may indeed mechanically carry the organ- 
ism, 14 its actual transmission in this manner to either a human 
being or a susceptible animal has not yet been demonstrated. 
On the other hand, Flexner and Lewis 15 have shown that not 
only the probable portal of entry but that of exit of the organ- 
ism, is the upper respiratory tract, for they were able both 
to successfully infect monkeys through the nasopharyngeal 
mucosa and to recover the virus from the nasal mucosa, 
even though the inoculation had been made through other 
channels. Conditions here are thus very similar to those 
which have been shown to exist in meningococcus menin- 
gitis, where Flexner 16 could demonstrate that following intra- 
spinous inoculation the corresponding organisms subsequently 
appeared both free and enclosed in leukocytes in the naso- 
pharynx. 

Corresponding studies in the human being revealed analo- 
gous conditions. It was thus found that here also the virus 
may be demonstrated by inoculation tests, both in the mucous 
membranes of the nasopharynx and in the nasopharyngeal 
secretion, 17 18 as well as in the tonsils 19 20 of patients who had 
died during the acute period of the malady. 



ACTIVE CARRIERS 143 

Active Carriers. — Subsequent investigation then showed 
that the virus may persist in the nasopharyngeal secretion 
of recovered cases for a long time while retaining its virulence 
not only for monkeys but also for human beings. Kling, 
Pettersen and Wernstedt 21 have thus reported an instance 
in which the virus could be demonstrated in the nasopharyn- 
geal swabbings and washings as late as 204 days (seven 
months) after the infection, and Lucas and Osgood 22 have 
described a case in which they found the virus in the nasal 
secretion of a child, four months after an attack. The same 
child had had an attack of the disease two years before, and 
the writers are inclined to think that it had harbored the 
organism during this entire time, and that the second attack 
was an exacerbation of the first. The same investigators 
had previously established that in recovered monkeys also 
the virus may be present for five months following an acute 
attack of the disease. 23 

That recovered convalescents who have actually been 
paralyzed may thus become carriers can hence be regarded 
as an established fact. But striking though this demonstra- 
tion has been, even more important is the discovery that 
the carrier state may also develop in the so-called, though 
wrongly termed, abortive cases, in which no paralytic 
symptoms develop. For these cases are after all far more 
dangerous to the community than the former, as they are 
very likely to be overlooked and to be wrongly interpreted 
not only by the parents but also by the attending physician, 
and especially so at a time when the disease is not occurring 
in epidemic form or when an epidemic has just begun. We 
now know that in the course of an epidemic these non- 
paralytic cases represent a very large proportion of the total 
number of infections. During the great Swedish epidemic 
Wickman 2 thus came to the conclusion that from 25 to 56 
per cent, of the total incidence of the disease was of this 
order, and expressed the belief that these figures even were 
probably too low. Muller, 24 while investigating an epidemic 
occurring in Hessen-Xassau, came to a similar conclusion. 
The commission appointed by Surgeon-General Blue, of the 
United States Public Health Service, to investigate the big 



144 



ACUTE POLIOMYELITIS 



New York epidemic of 1916, reported that the disease was 
"widely prevalent and most frequently of the non-paralytic 
type." 25 

That abortive convalescents may also harbor the causative 
organism in their nasopharyngeal secretions has been shown 
by Taylor and Amoss. 26 

Passive Carriers. — In addition to convalescent carriers the 
existence of passive, healthy carriers of the poliomyelitic virus 
has also been demonstrated. This was first accomplished by 
Flexner, Clark and Fraser 27 and subsequently confirmed by 
Kling and Pettersen 28 abroad and by Taylor and Amoss 26 
in the United States. 

In view of the cumbersome and expensive method which is 
unfortunately the only one thus far available for the purpose 
of demonstrating the presence or absence of the virus, viz., 
the inoculation of monkeys, a sufficiently extensive series 
of investigations to determine the average duration of the 
carrier stage, the incidence of abortive and paralytic, as well 
as of healthy carriers, has thus far not been possible. But 
the evidence which is actually available is sufficient to show 
the very real menace which the carriers represent not only 
in a community, but even to themselves, as is shown by the 
following examples: 

A little girl, aged four years, was taken ill on October 12 and 
admitted to the Rockefeller Hospital on October 17, where she 
was found to be suffering from severe anterior poliomyelitis. 
She was discharged on October 28. The child's parents were 
subjected to a nasopharyngeal irrigation with normal saline, 
150 c.c. of washings being obtained. This material was 
shaken and passed through a Berkefeld filter. 1.5 c.c. of the 
filtrate was injected into the sheath of each sciatic nerve 
and 140 c.c. into the peritoneal cavity of a Macacus cyno- 
molgus (monkey A) . On November 1 1 the animal was noted 
to drop his right leg. On November 12 this was flaccid and 
lumbar puncture yielded 2.5 c.c. of fluid containing an excess 
of leukocytes. On October 13 the animal was killed. Exami- 
nation of the cord, medulla and interstitial ganglia showed 
lesions typical of acute poliomyelitis. On December 3 two 
monkeys (B and C) were injected intraneurally and intra- 



PASSIVE CARRIERS 145 

peritoneally with a glycerinated emulsion of the spinal cord 
and medulla of animal A. On December 10 examination of 
the spinal fluid of C showed an excess of leukocytes, and on 
December 13 both legs were partially paralyzed. The animal 
was killed on December 13. In monkey B paralysis of the 
legs appeared on December 19; on December 21 the arms and 
back were weak and the paralysis was extending. The 
animal was killed on December 23. Examination of the cord 
and medulla and ganglia showed the typical infiltrative degen- 
erative lesions of poliomyelitis. 

Still other animals were subsequently injected with gly- 
cerinated emulsions of the nervous organs from B and C, 
and typical results obtained in these also. (Flexner, Clark 
and Fraser.) 

The investigation thus conclusively showed that one or 
both of the little girl's parents harbored the virus of the 
disease in the nasopharynx, and evidently was a healthy 
carrier, as neither showed any symptoms of illness at the 
time of the examination. 27 

A similar instance of the presence of one or more healthy 
carriers in a family where active poliomyelitis had occurred 
has been described by Kling and Pettersen. 28 

The patient in this case was an adult, aged forty-one years. 
He was taken ill on September 10; both legs became paralyzed 
on September 12 and death occurred on September 14 from 
respiratory failure The man's family consisted of a wife 
and three children, all of whom remained well. Nasal wash- 
ings in distilled water were obtained from all of these on the 
day following the death of the father. Combined, they 
amounted to one liter. This material was concentrated in 
the vacuum at 35° to 38° C. to 75 c.c, treated with the 
requisite amount of sodium chloride and filtered through a 
Berkefeld filter. A monkey (Macacus sinicus) was injected 
on September 20 intracerebrally with 0.5 c.c. and intra- 
peritoneally with 20 c.c. of the filtrate. Death resulted on 
October 2, both legs and the back being paralyzed. Sections 
of the cord showed moderate perivascular and diffuse infil- 
tration of the nervous tissue with mononuclear cells and 
neurophagocytosis. On October 3 a second Macacus was 
10 



146 ACUTE POLIOMYELITIS 

inoculated with an emulsion of the spinal cord of the first 
animal. Paralysis of the right leg occurred on October 13 
and of the left on October 14. The animal was killed on 
October 15, sections revealing typical lesions of poliomye- 
litis. 

Example, Illustrating the Possible Development of Poliomye- 
litis in a Carrier, Who was not III at the Time of the Examina- 
tion 26 (Taylor and Amoss). — On June 2, 1917, a youth, aged 
sixteen years, living at Waitsfield, Vt., attended a ball game 
at Northfield, Vt., and on his return home stopped in Mont- 
pelier for supper. At the time poliomyelitis existed at the 
latter place, but there had been no cases either at Waitsfield 
or at Northfield. On June 12 he was taken ill with headache, 
pain in the back and legs and vomiting; on June 13 he was 
found to have fever; by June 16 there was extensive paralysis 
involving both legs, the right triceps, the intercostals, 
pectorals and diaphragm. Examination of the spinal fluid 
showed the presence of 400 leukocytes per c.mm. and an 
excess of globulins. Death occurred on this date. 

The youth's family consisted of his parents, a sister 
(Hazel), aged thirteen years, and two brothers, aged ten and 
seven years, respectively. The two younger brothers (Everett 
and Dwight) slept in the same bed and in the same room 
with the elder brother. On the day of the latter's death 
Everett and Hazel were separately given a nasopharyngeal 
irrigation with distilled water; 60 c.c. were obtained from the 
one and 100 c.c. from the other. The material was treated 
with 10 per cent, of ether (which inhibits bacterial devel- 
opment, but leaves the poliomyelitis virus uninfluenced), 
shaken for two and a half hours with glass beads, centri- 
fugalized, filtered through a Berkefeld filter and concen- 
trated in the vacuum at 35° C. to about 2 c.c. One monkey 
(A) was injected with the concentrate obtained from the one 
child (E) and a second monkey (B) with that corresponding 
to the other (H) . Neither child had been away from Waits- 
field, and Hazel had been perfectly well at the time the 
washing was taken. Everett, however, was taken ill on the 
same day as his elder brother. He had fever and diarrhea, 
but recovered quickly, and on subsequent examination 



PASSIVE CARRIERS 147 

showed no signs of paralysis or muscular weakness, and no 
abnormality of the reflexes. 

Hazel was taken ill with fever and headache on June 21 ; 
on June 22 the reflexes were increased : there was stiffness of 
the back but no muscular weakness. These symptoms sub- 
sided gradually, but on reexamination on July 22, partial 
paralysis of the left deltoid, the right anterior tibial and of the 
abdominal muscles could be detected, so that there can be 
no doubt that she had passed through a mild attack of the 
disease. 

The two monkeys developed typical paralysis. A was not 
killed, but later, when the paralysis had become stationary, 
it was injected intracerebrally with a large dose of an active 
virus, with a negative result, showing that it had developed a 
high degree of immunity. B was killed and a third monkey 
C was inoculated with an emulsion of B's spinal cord and 
medulla, which resulted in paralysis and typical focal lesions. 

The third child (Dwight) was taken ill on June 18 with the 
same disease, and recovered following treatment with the 
serum from a recovered case. An examination of the nasal 
washings about two and a half months later gave a negative 
result. 

These findings suggest, of course, that the elder brother 
was infected either at the ball game or at Montpelier. Before 
falling ill himself he evidently conveyed the virus to one or 
more members of his family, with the> result that all the 
children became infected. Everett's case may possibly be 
viewed as an abortive case of the disease, while Hazel at 
the time of the examination evidently was a healthy carrier 
who subsequently developed the disease herself. 

In connection with the recital of these findings, Taylor and 
Amoss have raised the question whether in the final analysis 
every case of poliomyelitis may not develop from a carrier; 
in other words, whether a "carrying period" does not precede 
the outbreak of the malady in every case. As a matter of 
fact, such a view is not a startling one, and the observation 
in itself is quite in accordance with what has been noted 
in connection with typhoid fever, diphtheria, pneumonia, 
camp septicemia and meningitis. 



148 ACUTE POLIOMYELITIS 

Ogilvy 33 states that the epidemic which occurred at New 
Rochelle in 1916 and which gave rise to 125 cases of the 
disease was definitely traced to a carrier coming from an 
infected household in Brooklyn. 

Frequency of the Carrier State; Relative Insusceptibility to 
the Disease. — As regards the frequency of occurrence of 
poliomyelitis carriers, I have already pointed out that we have 
not as yet the necessary laboratory data to make any definite 
statement. But bearing in mind, on the one hand, the large 
number of non-paralytic cases which have been noted in the 
course of an epidemic, and, on the other, the relatively slight 
susceptibility to the disease on the part of those who are 
exposed, which Herrman 29 has estimated at not more than 2 
per cent., as contrasted with measles (90 per ceut.), whooping- 
cough (75 per cent.), scarlet fever (25 per cent.) and diph- 
theria (20 per cent ), it would seem reasonable to suppose 
that the number of carriers and above all of passive carriers 
must be far greater than the number of actual cases. Evidently 
the transmission of the organism from one person to another 
must take place very readily. We have thus seen that the 
elder boy of the family, studied by Taylor and Amoss, was able 
to infect his two younger brothers and sister either directly 
or indirectly within two weeks after his own and evidently 
very brief period of exposure on the day of the ball game. 
As a matter of fact, Everett and Hazel were carriers at 
that time, and may have been such even at an earlier date. 
The interesting question, of course, immediately arises: 
Why is it that the incidence of morbidity is so small in view 
of the ready transmissibility of the virus? This question, 
in a more or less modified form, of course, comes up for 
consideration in connection with the carrier problem in its 
relation to other infectious diseases. But whereas we know 
nothing whatever of the causes of this relationship in the 
other diseases which we have been considering, we have 
some information at any rate bearing on this problem in 
poliomyelitis, as will appear from the following consid- 
erations: 

The Inactivating Power of the Nasal Secretion upon the Virus 
of Poliomyelitis. —As the virus of poliomyelitis is found In the 



INACTIVATING POWER OF THE NASAL SECRETION 149 

nasal secretion of infected individuals, and as the disease 
may be produced through nasal inoculation, the thought has 
naturally suggested itself that if the disease does not develop 
in spite of the presence of the organisms in the nasopharynx, 
as in the case of healthy carriers, this might possibly be due 
to some property inherent in the nasal secretion itself. Such 
a hypothesis, of course, has many attractions, as quantitative 
differences in the degree of the inactivating or neutralizing 
power of the secretion would readily explain the development 
or non-development of the disease, the duration of the period 
of incubation and other factors, concerning which we have 
hitherto been completely in the dark. 

The problem in question has been studied by Amoss and 
Taylor. 30 These investigators have found that the washings 
from the nasal and pharyngeal mucosa of certain individuals 
actually possess the power to inhibit the infectious action of 
active poliomyelitis virus. To a certain extent this property 
seems to depend upon the integrity of the nasal mucosa, for 
of 8 normal adults, 6 furnished a material which protected 
the animal completely against a double lethal dose of the 
virus, while that obtained from the remaining 2 furnished 
no protection. Rhinoscopic examination showed that the 
anatomical condition of the nasopharynx in the latter 2 
was definitely abnormal. Amoss and Taylor conclude that 
while a distinct abnormality, such as an acute pharyngitis 
or rhinitis, may lead to a disappearance of the inactivating 
power, and with a return to the normal of the nose and 
throat, there must be still other factors involved of which 
we know nothing as yet, as fluctuations were also observed 
irrespective of the existence of any colds and the like. The 
fact remains, however, that the secretions in question fre- 
quently do possess the power to inactivate poliomyelitic 
virus, and it remains to be seen just what the findings will 
be in a series of healthy carriers, convalescent carriers, as well 
as during the different stages of the acute malady. It will 
be necessary, moreover, to ascertain whether in children, 
who are notoriously susceptible to the disease, the inactiva- 
ting property is more apt to be wanting than in adults. In 
the one child which was studied by Amoss and Taylor during 



150 ACUTE POLIOMYELITIS 

the acute period of the disease the washings did not neutralize 
the virus. In another child, in which the examination was 
made on the fifteenth day of the attack, neutralization oc- 
curred. Neither one of the two had received immune serum. 
In a third child which had been treated with serum, protec- 
tion was noted during the acute attack. The mixed washings 
from the children Everett and Hazel, referred to above, 
failed to neutralize the virus. This examination was made a 
month following Hazel's attack, and hence at a time when 
immunity must have existed. For this reason it is scarcely 
admissible to ascribe the neutralizing effect in the second 
case, just referred to, to that factor. It would be interesting 
to know whether the virus was still present in these various 
cases at the time of the examination. As the nasal washings 
were fractionally sterilized by heating at 60° C, the neutraliz- 
ing effect upon the added virus cannot, of course, be taken 
to indicate that the child in question was not a carrier. 

Manner of Infection. — As regards the manner in which 
infection is brought about, be this through an active case or 
a carrier, nothing definite is known. All that we can say is 
that poliomyelitis evidently belongs to that group of diseases 
in which infection takes place through the upper respiratory 
tract, and that the mode of infection is hence very likely 
the same as in meningitis, diphtheria, pneumonia and camp- 
septicemia. We may accordingly assume that the virus is 
transferred either directly through sputum spray, in whatever 
manner produced, or indirectly through the common use of 
eating and drinking utensils, through toys and the like, and 
possibly also through the inhalation of virus-laden dust. 
This latter possibility is suggested by the experiments of 
Neustaedter and Thro. 31 That the fly also may play a role 
in the transference of the virus has already been pointed out, 
although no instance has as yet been observed in which this 
has actually been proved. 

Maintenance of the Carrier State. — While we can readily 
see how the virus of poliomyelitis may be transferred from 
one person to another, we are as yet in complete ignorance 
regarding the conditions which make it possible for the organ- 
ism to maintain itself in the nasopharynx. We have seen 



MANAGEMENT OF THE CARRIER 151 

that normally the nasopharyngeal secretion is very apt to 
exercise a neutralizing effect upon the virus, in so far at least 
as its power to produce disease is concerned, but it is not 
known whether this inhibitory action is also directed against 
the growth of the organism in situ. Conceivably its pene- 
trating power might be affected, without impairment of its 
vegetative activity. However this may be, we are practi- 
cally driven to the assumption that the poliomyelitis organism 
also finds its habitat in those structures of the upper respira- 
tory tract which we have come to regard as the home of 
the meningococcus and the diphtheria bacillus in the corre- 
sponding carriers, viz., the lymphatic tissue. As a matter of 
fact, it has been shown by various observers 19 20 that the 
tonsils of fatal cases contain the virus of poliomyelitis, and 
Lucas and Osgood 32 have succeeded in demonstrating its 
presence in the tonsils of recovered monkeys. 

Demonstration of the Carrier State. — Unfortunately the only 
method which is thus far available to demonstrate whether 
an individual is or is not a carrier of the poliomyelitic virus 
is the animal experiment. The details of this procedure have 
already been given and need not be repeated at this place 
(see above). It is, of course, self-evident that such a cumber- 
some method, however important it may be for the purpose 
of investigating the various phases of the epidemiology of 
poliomyelitis, is almost useless when it comes to the practical 
control of an outbreak of the disease on a large scale. 

Management of the Carrier. — While we are not in the 
possession of a practical laboratory method by which we may 
determine whether or not a person is a carrier, or when the 
carrier stage has ended, we now know enough of the nature 
of the disease and its method of dissemination as to enable 
us to formulate certain general rules of control which will 
suffice to keep the malady within bounds if properly enforced. 

Quarantine. — As the patient himself is the primary focus 
of dissemination, hospitalization should be enforced whenever 
home conditions are such as to render the individual isolation 
from the remainder of the family impossible. In this manner 
the number of healthy carriers whom we must regard after 
all as the greater menace will of necessity be diminished, 



152 ACUTE POLIOMYELITIS 

care being taken, of coarse, that at the hospital also suitable 
precautions are maintained to guard against the develop- 
ment of carriers among the attendant personnel (gowning, 
capping, masking). When hospitalization cannot be carried 
out, isolation of the patient and his nurse should be insisted 
upon, with a release from quarantine of those who do not 
come in contact with the one or the other, while rigid quar- 
antine of the entire household should be enforced if isolation 
of the patient is not possible. Quarantine, when it is deemed 
necessary, should be extended particularly to children, either 
of an infected house, or an infected neighborhood, or of an 
entire commanity, according to the urgency of the situation. 

Regarding the duration of quarantine three weeks is now 
regarded as sufficient. This view is, of course, not based 
upon the results of laboratory work but upon general epi- 
demiological observations. Shaw 25 reports that an analysis 
of 36 primary and secondary cases showed that the longest 
period that a primary case was actually observed to be infec- 
tious was eight days, and in most cases only one or two days, 
so that three weeks would render ample and sufficient pro- 
tection. That this may suffice for most cases is undoubtedly 
true, but that the chronic carrier will escape under this 
regulation is also unquestionable. But unfortunately we 
have no alternative so long as we have no practical method 
available for determining whether a person is still a carrier 
or not. 

It has been suggested that in the management of an epi- 
demic passive immunization of exposed individuals with the 
serum of recovered cases would appear to be indicated. This 
seems logical and should be carried out whenever possible, 
bearing in mind, however, that passive immunization can 
hardly be expected to affect the carrier state and that quaran- 
tine and disinfection must be our mainstays of defense. 

BIBLIOGRAPHY. 

1. Caverly: Jour. Am. Med. Assn., 1896, vol. xxv, p. 1. 

2. Wickman, J.: Beitrage zur Kenntniss der Heine-Medinschen Krank- 
heit, Berlin, 1907, Die akute Poliomyelitis, ibid., 1911. 

3. Landsteiner, K. and Popper: Ztschr. f. Immunitatsforsch., Orig. 
1909, vol. ii, p. 377. 



BIBLIOGRAPHY 153 

4. Knoepf elmacher : Med. Klin., 1909, vol. v. 

5. Flexner, S., and Lewis, P. A.: Jour. Am. Med. Assn., 1909, vol. liii, 
p. 1639. 

6. Strauss and Huntoon: New York Med. Jour., 1910, vol. xci, p. 64. 

7. Flexner, S., and Lewis, P. A.: Jour. Exp. Med., 1909, vol. xii. 

8. Leiner and v. Wiesner: Wien. klin. Wchnschr., 1909, vol. xxii, p. 1698. 

9. Landsteiner, K., and Levaditi: Compt. rend, de la Soc. de biol., 
November, 1909. 

10. Idem. Ibid., December, 1909. 

11. Flexner, S., arid Lewis, P. A.: Jour. Am. Med. Assn., 1909, vol. liii, 
p. 2095. 

12. Flexner, S., and Noguchi, H.: Experiments on the Cultivation of the 
Microorganism Causing Epidemic Poliomyelitis, Jour. Exp. Med., 1913, 
vol. xviii, p. 461. 

13. Rosenau, M. J.: The Mode of Transmission of Poliomyelitis, Jour. 
Am. Med. Assn., 1913, vol. lx, p. 1612. 

14. Flexner, S., Clark, P. F., and Amoss, H. L.: A Contribution to the 
Epidemiology of Poliomyelitis, Jour. Exp. Med., 1914, vol. xix, p. 195. 

15. Flexner, S., and Lewis, P. A.: Jour. Am. Med. Assn., 1910, vol. liv, 
p. 1140. 

16. Flexner, S.: Ibid., 1910, vol. lv, p. 1105. 

17. Flexner, S., and Lewis, P. A.: Ibid., vol. liv, p. 535. 

18. Landsteiner, K., Levaditi, C, and Dannilesco: Compt. rend, de la 
Soc. de biol., 1911, vol. lxxi, p. 558. 

19. Landsteiner, K., Levaditi, C, and Pastia, C: Semaine med., 1911, 
vol. xxxi, p. 296. 

20. Flexner, S., and Clark, P. F.: Jour. Am. Med. Assn., 1911, vol. lvii, 
p. 1685. 

21. Kling, C, Pettersen, A., and Wernstedt, W. : Investigations on Infan- 
tile Paralysis. Communications de l'lnst. med. etat a Stockholm, 1912, vol. 
hi, p. 5 (Internat. Cong, of Hyg. and Demography, Washington, 1912). 

22. Lucas, W. P., and Osgood, R. B.: Transmission Experiments with 
the Virus of Poliomyelitis, Jour. Am. Med. Assn., 1913, vol. lx, p. 1611. 

23. Idem. Ibid., 1911, vol. lvii, p. 495. 

24. Mtiller, E. : Die spinale Kinderlahmung, Berlin, 1910. 

25. Quoted by Shaw, H. L. K. : Results of the Recent Epidemic of Polio- 
myelitis in New York State, Jour. Am. Med. Assn., 1917, vol. lxix, p. 168. 

26. Taylor, E., and Amoss, H. L.: Carriage of the Virus of Poliomyelitis 
with Subsequent Development of the Infection, Jour. Exp. Med., 1917, 
vol. xxvi, p. 745. 

27. Flexner, S., Clark, P. F., and Fraser, F. R.: Passive Human Carriage 
of the Virus of Poliomyelitis, Jour. Am. Med. Assn., 1913, vol. lx, p. 201. 

28. Kling, C, and Pettersen, A.: Deutsch. med. Wchnschr., 1914, vol. 
xl, p. 320. 

29. Herrman, C: The Age and Seasonal Incidence and Communica- 
bility of Acute Poliomyelitis (New York City Epidemic of 1916), Jour. Am. 
Med. Assn., 1917, vol. lxix, p. 163. 

30. Amoss, H. L., and Taylor, E.: Neutralization of the Virus of Polio- 
myelitis by Nasal Washings, Jour. Exp. Med., 1917, vol. xxv, p. 507. 

31. Neustaedter and Thro: New York Med. Jour., 1911, vol. xciv, p. 813. 

32. Osgood, R. B., and Lucas, W. P.: Transmission Experiments with the 
Virus of Poliomyelitis, Jour. Am. Med. Assn., 1911, vol. lvi, p. 495. 

33. Ogilvy, C. : A Report of a Group of One Hundred and Ten Cases 
of Poliomyelitis, Jour. Am. Med. Assn., 1917, vol. lxix, p. 691. 



PNEUMOCOCCUS PNEUMONIA. 

In view of the rarity with which pneumonia was known 
to develop through contact, and the presence, in the mouths 
of a large percentage of healthy individuals, of pneumococci 
which supposedly did not differ from those found in pneu- 
monic lungs, it was generally and not unnaturally assumed 
in the past that the outbreak of the disease in an individual 
took place in consequence of an auto-infection. The situa- 
tion, as formerly understood, might well be compared to the 
presence about the body of many persons of some high 
explosive, the detonation of which might lead to the indi- 
vidual's destruction at any time. According to this view all 
persons harboring the pneumococcus in their mouths truly 
lived constantly with the sword of Damocles suspended 
above them. 

Varieties of the Pneumococcus in Their Relation to Pneu- 
monia. — This idea had to be abandoned, however, when it 
could be shown that although culturally and morphologically 
pneumococci might appear alike, differences exist, neverthe- 
less, which are sufficiently marked and constant as to warrant 
a division of these organisms into different groups. In the 
United States, Dochez and Gillespie 1 thus showed that the 
pneumococci derived from cases of lobar pneumonia may be 
roughly divided into two groups, of which the larger, com- 
prising about 80 per cent, of the strains, can be further 
divided into three smaller groups, which were termed groups 
I, II and III, respectively. The remaining 20 per cent, 
correspond to group IV. In their earlier work Dochez and 
Gillespie demonstrated that groups I and II gave perfectly 
distinct immunological reactions, while group III was sepa- 
rated from these, as well as from group IV, on morphological 
and cultural grounds. Hanes 2 subsequently showed that 
representatives of the third group also can be distinguished 
from the remainder by specific serum reactions. These three 



THE PNEUMOCOCCUS AND PNEUMONIA 155 

types are now viewed as constants and can readily be distin- 
guished from each other, and the fourth group, which latter 
seems to consist of a series of independent varieties that do 
not cross in their immane reactions either with representa- 
tives of groups I, II and III or with each other. Still later 
Avery 3 found that among the representatives of group II 
there are certain ones which, while conforming in a general 
way to the second type, yet differ from this and from each 
other. These he termed II a, II b, and II x. 

Similar studies made in Germany by Neufeld 4 showed that 
pneumonia there also was in part associated with pneumo- 
cocci of the American types I and II, and much earlier 
Schottmuller 5 had already drawn attention to the fact that 
the pneumococcus mucosus (American type III) may be 
the causative agent of lobar pneumonia. In South Africa, 
Lister 6 encountered five groups of pneumococci in pneumonia 
patients, of which three are identical with types I, II and III 
of the United States and of Germany, while the other two 
have not yet been found outside of South Africa, and of 
these one group appears to be dominant among the lobar 
pneumonias of that country. 

On studying the distribution of the fovr American types, 
Dochez and his collaborators Gillespie and Avery 7 found 
that in New York 145 cases of the disease could be classified 
as follows : 

1912-13, 1913-14, Average, 

per cent. per cent. per cent. 

Group I 47 30 38.5 

Group II 18 39 28.5 

Group III (mucosus) 13 8 10.5 

Group IV (heterogeneous) ... 22 23 22 . 5 

Corresponding figures have since been obtained by 
Clough, 26 Sydenstricker and Sutton, 25 Hartmann and Levy, 27 
and others. 

On extending their studies to the flora of the mouths of 
healthy individuals and taking care to exclude, as far as 
possible, persons who had been in direct contact with pneu- 
monia, Dochez and Avery 7 then found that the pneumococci 
which were here encountered almost invariably were of the 
heterogeneous order, which seem to be responsible for roughly 



156 PNEUMOCOCCUS PNEUMONIA 

20 per cent, of the cases of lobar pneumonia, while organisms 
belonging to the fixed types were only exceptionally met with. 
They showed, furthermore, that as convalescence proceeds 
in those cases in which fixed types were found while the dis- 
ease was in actual progress, these disappear and are replaced 
by organisms which are indistinguishable from those found 
in the mouths of normal persons. 

As detailed studies, moreover, furnished no evidence that 
a mutation of pneumococci takes place in the course of an 
infection, the writers very properly conclude that our 
former concept regarding the origin of pneumonia is no longer 
tenable for at least 75 per cent, of the cases. 

Active Carriers. — In view of the rapidly accumulating evi- 
dence connecting the dissemination of various infectious 
diseases with healthy human carriers, the idea naturally 
suggested itself that in the fixed types of pneumonia, at any 
rate, carriers might also play a role. That the convalescent 
pneumonic may indeed be a potential carrier was found by 
Dochez and Avery 8 quite early in the course of their investi- 
gations. For in studying the disappearance of the fixed types 
and their replacement by organisms belonging to group IV 
they observed that while the fixed types may disappear as 
early as the twelfth day after the onset of the malady, they 
may remain much longer, and in 4 instances, i. e., in 20 per 
cent, of their first series of 20 cases, type organisms were still 
present at the time that the patient was lost to observation — 
& period varying between thirty and ninety days from the 
onset of the disease. 

Passive Carriers. — The epidemiological significance of these 
findings was then further emphasized when the same observers 
could show that whereas organisms belonging to groups I 
and II are found only very exceptionally in the mouths of 
individuals who have not been in contact with pneumonia, 
they are quite commonly met with in persons who have been 
in close contact with patients suffering from the disease in 
question, and that the type corresponds to that of the 
patient. They thus found that among 41 contacts corre- 
sponding to 30 patients who harbored either type I or type II, 
the corresponding type was present in 13. This means that 



PASSIVE CARRIERS 157 

for every 100 patients of this order we may assume the exis- 
tence of 43 carriers harboring the same type of organism. 
As the latter were found to remain in the throats of such 
individuals for a period of time varying between seven and 
forty-five days, and as the types in question are responsible 
for some 60 per cent, of the pneumonia cases and the majority 
of the deaths resulting, the conclusion suggests itself that 
the dissemination of pneumonia of this order may occur in a 
manner analogous to the dissemination of meningitis, diph- 
theria, typhoid fever, cholera, etc.; in other words, through car- 
riers, which here as there may be convalescents from the disease, 
but which for the most part probably are apparently normal 
individuals, who have acquired the carrying state through 
contact. 

Later investigations have largely confirmed these earlier 
findings. Stillman 9 10 in his analysis of 454 cases of lobar 
pneumonia admitted to the wards of the Hospital of the 
Rockefeller Institute during a period of five years thus found 
practically the same distribution of types as that originally 
given by Dochez and his co-workers (see above). The fol- 
lowing table represents an anlaysis of 19 cases in which the 
sub-types Ha, lib and Hx are also considered: 

No of cases. Percentage. 

Type I 151 33.26 

II 133 29.29 

II a 6 1.32 

lib 4 0.88 

II x 9 1.98 

III 59 12.99 

IV 92 20.26 

A further study of the varieties of pneumococci found in 
normal mouths was based upon 297 individuals who had not 
been in direct contact with lobar pneumonia. Of these 116, 
i. e., 39 per cent., harbored organisms of the pneumococcus 
type, and they in turn could be classified as follows: 

No. of cases. Percentage. 

Type I 1 0.8 

II 0.0 

II a 1 0.8 

lib 7 5.8 

II x 14 11.6 

III 34 28.1 

IV 64 52.9 



158 



PNEUMOCOCCUS PNEUMONIA 



These findings are in striking contrast to those which were 
obtained in an analysis of 184 normal individuals who were 
known to have been in contact with lobar pneumonia of types 
I or II. 

Total No. No. infected. Per cent. 

In contact with type I . . 107 16 15 

" II . . 77 5 6 



In contact with types I or II 184 



21 



11 



It will be noted that whereas among non-contacts only 0.8 
per cent, of the cases examined harbored organisms of types 
I and II, among known contacts this figure rose to 11 per 
cent. 

Frequency of Passive Carriers. — A very good idea of the 
extent to which pneumococci of the fixed types probably 
occur among the inhabitants of a large community is afforded 
by Stillman's analysis of the saliva of 942 normal individuals, 
selected at random, but including the series of contacts just 
considered. Pneumococci were found in 450 instances, i. e., 
in 47 per cent. Type analysis gave the following results: 



Type I 
II 



II a 
II b 
II x 
III 
IV 



No. of cases. 
. 34 

22 
1 

26 

47 

85 
. 271 



Percentage. 

7.0 

4.5 

0.2 

5.3 

9.7 
17.5 
55.8 



In commenting upon these findings, Stillman states that 
of the 34 cases in which type I was found 33 had been in 
intimate contact with lobar pneumonia of the same type. 
Of the 22 individuals harboring type II 19 had recently been 
in close contact with pneumonia of that type. 

Regarding the significance of the occurrence of types II b, 
II x and III in normal individuals, Stillman concludes that 
they must be viewed as normal inhabitants of healthy mouths 
and that their import is essentially the same as that of type 
IV, bearing in mind, however, that type III, when it does 
cause pneumonia, produces a form which is more fatal than 
any other, giving a mortality of some 60 odd per cent. 



PASSIVE CARRIERS ' 159 

An interesting analysis of the types of pneumococci which 
may be found in individuals who at the time are not suffer- 
ing from pneumonia has further been made by Miriam 
Olmstead. 11 Her series comprises 2477 surgical cases of all 
kinds who were examined for types before operation, with 
the idea of ascertaining the relationship of postoperative 
pneumonias to the organisms that were present before surgi- 
cal treatment was instituted. Of this number 798, i. e., 
32.2 per cent., harbored pneumococci at the time of examina- 
tion, a type analysis of which gave the following results: 

No. of cases. Percentage. 

Type I . . 5 0.6 

"II 10 1.2 

Atypical II 90 11.2 

Type III 104 13.0 

"IV 589 73.8 

Of the 5 individuals harboring type I, one gave a history 
of contact with a case of pneumonia, and this was the only 
one of that order that developed postoperative pneumonia. 

From these data we may conclude that, as Dochez and 
Avery first claimed, types I and II are indeed practically 
only found in patients and convalescents of those types, and 
in individuals who have been thrown into more or less inti- 
mate contact with such cases, and it would follow that we 
may rightfully regard individuals harboring these organisms, 
be they convalescents or healthy, as carriers, comparable to 
other human carriers of infectious disease, and hence as 
important factors in the dissemination of lobar pneumonia 
of these types. This being so, we may assume, as in the case 
of other infectious diseases of this order, that the danger aris- 
ing from the patient himself is in all probability less than 
from the healthy carrier, as the former is confined to his bed 
and is brought into contact with relatively few persons only 
during the greater period of his carrying stage, while the 
healthy carrier mingles with the community at large. The 
latter is not conscious of his fatal gift; moreover, he is not 
suspected by others, and is no doubt capable of producing 
still other carriers, so that through him individually or 
through such secondary carriers a widespread dissemination 
of the organisms may occur, and thus reach susceptible indi- 



160 PNEUMOCOCCUS PNEUMONIA 

viduals in whom the disease itself then develops. That the 
carrier himself does not necessarily fall ill of pneumonia has 
been definitely established, but that he may do so is shown 
in the protocols accompanying the papers of Dochez and his 
co-workers. 

Duration of the Carrier State. — As regards the duration of 
the carrying period for types I and II on the part of normal 
individuals, Stillman found as average for the former twenty- 
five days and for the latter forty-three days. The longest 
period was eighty days (in a type I case). 

Common Colds as Sources of Pneumonia. — In this connection 
it is interesting to note that pneumococci of the fixed types 
may be encountered in the nasal secretion and sputum of 
ordinary colds, in the absence of any history of contact with 
pneumonia cases. Such individuals may accordingly be 
regarded as potential sources of infection for others. In a 
study of 65 cases of common colds Valentine 28 thus found 
pneumococci in 37 by animal inoculation, and in 6 additional 
cases by plating on blood agar. Of the total of 43 cases, 2 
were of type I, 2 of type II, 4 of type III and 35 of type IV. 
The 2 cases of type II and 1 of type III gave a history of 
contact with pneumonia, while in the remaining cases of the 
fixed types no such history could be obtained. In 1 of the 
type I cases the corresponding organism could be demon- 
strated even after a year. 

The question, of course, arises whether these cases were 
not all contact, i. e., passive carriers, even though no history 
of contact could be obtained. On the other hand, the idea 
suggests itself that cases of this order may be comparable to 
cases of meningococcus pharyngitis, viz., that in addition to 
the orthodox picture of a pneumococcus infection of the lung, 
there may be milder types in which only the upper respira- 
tory tract is involved, and that in addition to the carriers 
convalescent from the severer malady, there may be carriers 
resulting from the minor infections. The fact that the organ- 
isms were found by Valentine in large numbers suggests that 
the latter possibility indeed exists. 

Habitat of the Organisms. — Regarding the habitat of the 
pneumococci in healthy carriers our knowledge is practically 
nil. The results reached by the investigators mentioned in 



HABITAT OF THE ORGANISMS 161 

the foregoing pages have reference either to cultures taken 
from the saliva or the sputum, but this does not of necessity 
imply that the organisms multiply on the free mucous sur- 
faces. From corresponding observations made in connection 
with diphtheria and meningitis we have reason to assume that 
organisms found upon the free surfaces are there more or 
less accidentally, and that their actual habitat is in the crypts 
of the tonsils or the various nooks and corners connected with 
other lymphatic structures of the throat and the posterior 
nares. In cases of pneumonia, of course, we know that the 
pneumococci are present in abundance in the exudate, and 
it is easily conceivable that from here they may be distributed 
upward over the bronchial and tracheal mucosa, and that 
during the act of coughing and expectoration the larynx, 
pharynx and mouth of the individual also become contami- 
nated. This, however, raises the question whether pneu- 
monia is not a descending infection, which is the view that 
is now generally held. But in that case we would have a right 
to assume that every pneumonic was for a while a passive 
carrier until a sufficient number of organisms became avail- 
able to bring about such a complete overthrow of the natural 
defences as to render an infection of the lung possible. And 
in that case the question, where does this initial develop- 
ment take place, still remains unanswered. But supposing 
even that the infection were an ascending one, it is more than 
likely that the primary focus is nevertheless located in the 
upper respiratory tract. In the healthy carrier, of course, 
there is no reason for assuming that the organisms come from 
the deeper portion of the respiratory tract. In the absence 
of definite information on the subject we can only surmise 
that in the pneumococcus carriers also the crevices of the 
lymphatic structures of the upper respiratory tract contain 
foci in which the organisms find suitable conditions for their 
development, and from which they find their way to the sur- 
face and into the saliva. The fact that they are so frequently 
present in the latter, in which the diphtheria bacillus and the 
meningococcus are only exceptionally found, would further 
suggest that they might develop in diseased areas about the 
teeth. Streptococci are here so constantly met with that it 
would not be at all surprising if pneumococci also here found 
11 



162 PNEUMOCOCCUS PNEUMONIA 

conditions favorable for their growth. Dochez, Avery and 
Stillman when speaking of their findings in individuals who 
were not or had not been suffering from pneumonia quite 
constantly refer to "normal mouths." But every one knows 
that relatively few mouths are normal, and from the stand- 
point of the epidemiology of lobar pneumonia it would seem 
most important to ascertain whether or not pneumococcus 
carriers actually do have normal " mouths," which would, 
of course, include the condition of the teeth. A systematic 
investigation in this direction would suggest itself as a most 
promising field for future investigation. 

Mode of Infection. — Regarding the manner in which the 
pneumonia patient produces carriers, and these in turn infect 
others, we are, of course, most liable to think of a direct 
transfer of the organisms through sputum spray. While 
this no doubt can occur, there is reason for believing that 
infection may also take place through the dust of rooms in 
which patients or carriers live or have lived. Recent inves- 
tigations in connection with the dissemination of strepto- 
cocci, even in cubicle wards, have shown how readily this 
can occur when all other channels for the transfer have prac- 
tically been eliminated and air currents and dust remained 
as the only possible factors. 12 Stillman 13 has investigated 
this possibility in connection with the types of pneumonia 
that we are considering and obtained results which speak 
for themselves. 

TYPE ANALYSIS OF DUST OBTAINED FROM ROOMS. 

Percentages Percentages 

No. of of positive No. of of positive 
rooms (a) . findings. rooms (6) . findings. 

Type I 1 5.5 25 33.78 

"II 0.0 23 31.08 

" II a 0.0 0.0 

" lib 4 22.0 2 2.7 

" II x 3 16.6 2 2.7 

"III 2 11.0 2 2.7 

" IV ..... . 8 44.4 20 27.02 

Pneumococci present in .18 29.0 74 40.0 

" absent in .44 71.0 109 59.6 

62 183 

a, in which no pneumonia had occurred; b, in which pneumonia had 
occurred. 



PNEUMOCOCCUS CARRIERS IN DISEASE 163 

The fact that a pneumococcus of type I was found in 
a single instance in a house in which no pneumonia had 
occurred can, of course, be no more surprising than the occa- 
sional finding of the same type or type II in the mouth of a 
person giving no history of contact with pneumonia. For so 
long as we recognize the existence of carriers we must also be 
prepared to find secondary carriers resulting through contact 
with primary ones, and such persons would naturally give no 
history of contact, but could cause a dissemination of the 
organisms in their surroundings. 

Stillman also found that, as a rule, the dust became nega- 
tive before the carriers, living in the same household in which 
a case of pneumonia of type I or II had occurred. But in 
two instances the dust remained positive longer than the 
carriers. The most persistently positive dust was gotten 
from two homes in which the most persistent carriers lived. 
In one of these (type I) the dust was positive for fifty days 
while the carrier had not become negative at the end of 
eighty days. In the other (type II) the carrier was still 
positive at the end of seventy days and the dust on the 
fifty-seventh. We may conclude that there is good reason 
to believe that both patient and carrier may infect others 
not only directly, but also indirectly through pneumococcus- 
laden dust, and it would seem as though the latter method 
were indeed the more likely. This observation in no way 
detracts from the importance of the carrier as a factor in the 
dissemination of the disease. He is a menace to the com- 
munity because he contaminates the air, while the typhoid 
carrier is a menace because he contaminates the food and 
drink. 

Examples Illustrating the Role of Pneumococcus Carriers in 
the Dissemination of the Disease. — As yet but little work has 
been done with the view of demonstrating in a concrete 
manner the relationship between actual cases of lobar pneu- 
monia and carriers. Bearing in mind the relatively brief 
duration of the carrier period, the mobility of the individual 
and the possibility — indeed, the likelihood — that he may 
bring about the dissemination of the disease through infec- 
tion of the dust of rooms in which he may have lived for 



164 PNEUMOCOCCUS PNEUMONIA 

only a short time, it will be realized that not every case of 
pneumonia will lend itself to a fruitful investigation of its 
origin. In large communities such an investigation will 
perhaps only exceptionally be a profitable one. A few well- 
chosen instances, however, properly studied, will suffice for 
our purposes. Stillman has related several examples which 
practically leave no doubt that the carrier of pneumococci 
of the types we have been considering in reality does play 
the role which Dochez and Avery's work has suggested. 
One instance which seems especially suggestive is the follow- 
ing: 14 "A patient was admitted to the hospital suffering 
from pneumonia due to pneumococcus, type I. Specimens 
of sputum were obtained from the other members of the 
household. One five-year-old daughter was found to be a 
type I carrier ; the other two members of the household were 
negative. The dust of the room which the patient had pre- 
viously occupied in this house also showed a type I pneu- 
mococcus. The little girl was sent to board with friends 
while her mother was in the hospital. She spent three days 
with the first family and then went to visit in the Bronx. 
Six days after she left, a child in the home where she had 
visited came down with pneumonia, due to pneumococcus 
type I. Specimens of sputum from the other members of 
this household were negative, but from the dust in the sick 
child's room a pneumococcus of type I was isolated. At the 
home in the Bronx where the little girl visited for ten days 
no case of pneumonia developed and the sputum of the 
members of this family as well as the dust failed to show the 
presence of pneumococcus type I. The child next went to 
visit friends in Brooklyn. Although the sputa from the 
members of this household were negative, from the dust a 
type I pneumococcus was recovered." 

Quite instructive also is the following case: A patient 
who had just recovered from a type I pneumonia left the 
hospital March 9. The next day he went to see his brother 
who had developed a type II pneumonia. On March 12 the 
same individual who had just recovered from the type I 
infection developed a pneumonia due to a type II pneumo- 
coccus, 






PNEUMOCOCCUS CARRIERS IN DISEASE 165 

An interesting contribution to the epidemiology of pneu- 
monia, based upon type determination, has also been made 
by Sydenstricker and Sutton, 25 and is here given as originally 
reported. 

Sparrows Point is the home of the Maryland Division of the 
Bethlehem Steel Company. It is situated on the waterfront 
near the mouth of the Patapsco River, about 10 miles below 
Baltimore. The plant employs about 7000 men. Some have 
homes in Baltimore, but the majority live in the town which 
has grown up around the plant. About 2000 of the men are 
negroes. Half of these live in the company's shanties, in a 
section of the works called "Coke Oven Row." This group 
of shanties is shown in Fig. 3, which is reproduced from the 
company's map with their consent. The shanties are built 
ten in a row. Each accommodates four men. The shanty 
is a small room fourteen feet square, with four bunks, four 
lockers, a washstand and a stove. One building is used as a 
store, barber-shop and pool-room. This is a common meet- 
ing-place, and usually crowded. Most of the men get their 
own meals, but there is a cook-shop which some of the men 
use. 

Formerly all the shanties were frame buildings, the wall 
being a single thickness of board. Recently a group of 100 
tile and concrete shanties has been added. The shanty group 
is situated directly on the shore, and is consequently exposed 
to all sorts of weather. The majority of our pneumonia 
cases came from this Coke Oven group. The view commonly 
held among the company's physicians is that pneumonia 
has always had a high incidence and been of a severe form 
among these men in the shanties. 

The group seems to offer excellent opportunities for epi- 
demiological studies. It is an isolated group of 1000 men 
living under almost identical conditions. They are in inti- 
mate contact with each other and with no one else. They 
crowd into the store or into each other's shanties. They 
frequently close the two small windows and door, and, in 
addition, try to pack the cracks between the boards with 
newspaper, especially in winter, to keep out the cold. They 
sleep sometimes with the stove lit, or, if too tired to start a 



166 



PNEUMOCOCCUS PNEUMONIA 



fire, they sleep without it, often with too few blankets. Thus 
these men are exposed to sudden changes of temperature. 
Few of them, however, are exposed to the heat of the furnaces, 
since practically all are employed on outside work. Another 
factor, which may play a role in their susceptibility, is that 



Frame SAajiti.es 

it 




Fig 3. 



most of them come from the south and are not used to winters 
as severe as in this climate. 

It is this group, then, that we undertook to study. We 
collected, during the latter part of January, specimens of 
sputum from 100 of these men. In Fig. 3 the types are 
spotted on their respective shanties. The figures by the 



PNEUMOCOCCUS CARRIERS IN DISEASE 167 

shanties give the types of the cases of pneumonia from each 
shanty which were treated in the hospital. 

Of the four men employed in the cook-shop, one carried a 
type I, one a type II, the other a type IV, and one was free 
from pneumococci. 

The sputa were collected in sterile bottles, brought imme- 
diately to the laboratory and white mice then inoculated 
with 0.5 c.c. of sputum subcutaneously. The mice were 
allowed to die and cultures made from the peritoneum and 
from the heart's blood. The pneumococci were usually 
obtained in pure culture. 

In order to have a normal group with which to compare 
them, we cultured in a similar way 50 sputa collected at 
random among our dispensary patients. The results of these 
studies are tabulated in Table III. The striking difference 
is in the high incidence of the fixed types on the Coke Oven 
group — the number of type IV pneumococci is practically 
the same, the difference being in the small number of negative 
cultures in the Sparrows Point group. The high incidence 
of fixed types among the mouth organisms parallels the high 
percentage of fixed-type pneumonias and the extremely low 
percentage of cases due to the type IV pneumococcus among 
Coke Oven Row cases, as contrasted with our city cases of 
pneumonia in Table IV. Another point is a pneumonia 
morbidity rate at Coke Oven Row of approximately 6 per 
cent., which is very high in comparison with the Health 
Department rate for Baltimore City of less than 0.5 per cent. 
The latter is an estimate based on the Health Department 
mortality rate The mortality of the Sparrows Point group 
is shown in Table V. It varies little from the rates given 
for the eutire group. 

Several interesting features warrant special mention. In 
Shanty 609 we collected sputa from six men. Two contained 
atypical type II pneumococci, one a type IV and three 
yielded no pneumococci. One of the last group later devel- 
oped a type I pneumonia. In Shanty 43 all four men devel- 
oped pneumonia the same day, following a sudden fall in 
temperature. One was treated in another hospital in this city. 
The type of pneumococcus was not determined in this case. 
One refused hospital care and went to his home in the south. 



168 PNEUMOCOCCUS PNEUMONIA 

The other two came here. They had type I and atypical 
type II infections, respectively. They stayed together in a 
side room by themselves the entire time. The one that was 
recovering from the atypical type II infection suddenly 
relapsed after his temperature had become normal. A lobe 
in the opposite lung from the one previously involved became 
consolidated. His blood cultures again became positive. 
This time a type I pneumococcus was isolated. Prior to the 
isolation of the type I organism, the development in the 
patient's serum of antibodies active toward the atypical type 
II strain suggested that we would find that the new consolida- 
tion was due to a pneumococcus of an entirely different strain. 
This patient received antipneumococcus (type I) serum and 
made an uneventful recovery except for a moderate serum 
sickness. If he contracted the type I infection from his 
shanty-mate in the hospital, it is interesting that he con- 
tracted a different type in the shanty. 

Summary. — Examination of 100 specimens of sputum from 
healthy negroes living in the shanties of the Bethlehem Steel 
Works showed 22 per cent, of pneumococci belonging to fixed 
types in contrast to 6 per cent, of a group of our dispensary 
patients. The number of the ordinary saprophytic type IV 
organisms was practically identical in the two groups. The 
increase in the fixed types was at the expense of the group 
that do not harbor pneumococci in their mouths. This high 
percentage of healthy individuals carrying pneumococci of 
fixed types in their mouths occurred in a community where 
the percentage of cases of lobar pneumonia due to organisms 
of fixed types was likewise verv high. 

TABLE I. — SUMMARY OF CASES. 

Black. White. 

Type. Living. Dead. Living. Dead. Total. 

I 12 6 3 3 24 

II 3 10 4 

II (atypical) 7 4 1 12 

IV .15 2 3 2 22 

Ungrouped 1 1 2 

Streptococcus mucosus ... 1 00 1 

Friedlander's bacillus ... 01 1 

Total 39 13 7 7 66 



RECOGNITION OF THE PNEUMOCOCCUS CARRIERS 169 



TABLE II. — MORTALITY RATES. 

Black. White. Mixed. 

Type. Per cent. Per cent. Per cent 

1 33.3 50 41.7 

II 0.0 \ q 

II (atypical) .... 36.3 100 41. 6** 

IV 11.8 40 18.2 

Mixed 25.0 50 30.3 



TABLE III. — PNEUMOCOCCI ISOLATED FROM MOUTHS OF 

HEALTHY INDIVIDUALS. 

Sparrows Point Dispensary 

(100 cases). (50 cases). 

Type. Per cent. Per cent. 

I 6l 01 

II 6 I 22 2 I 

II (atypical) 4 f ^ 2 f D 

III 6 J 2 J 

IV 35 32 

None 43 62 

100 100 

Other examples of a convincing character will, no doubt, 
soon become available now that the mode of transmission 
of the more dangerous types of respiratory infections is 
being studied with such care in our army camps, but the 
few instances just related suffice to show that the danger 
from the pneumococcus carrier is a very real one. 

The Recognition of the Pneumococcus Carriers. — The recog- 
nition of pneumococcus carriers of the types which we have 
been considering in the foregoing pages involves two essen- 
tial steps: viz., the isolation of the organism in pure culture 
and the study of its behavior toward agglutinating or precipi- 
tating antisera. 

Isolation of the Organism. — Owing to the fact that in carrier 
studies sputum, properly speaking, is usually not available, 
some of the simpler methods of investigation which furnish 
such excellent results in type determination in actual cases 
of pneumonia can unfortunately be used only in part. The 
material with which we are obliged to work is either a 
swab specimen from the throat or a sample of saliva, and as 
contaminating organisms cannot here be removed by any 



170 PNEUMOCOCCUS PNEUMONIA 

mechanical method it is necessary to inoculate white mice 
in order to obtain pure cultures. This is time-consuming and 
calls for a large number of animals, but cannot be avoided. 

A few drops of saliva (0.2 to 0.3 c.c.), which should be col- 
lected in a sterile bottle and taken to the laboratory at once, 
are injected intraperitoneally into mice. The animals are 
killed the next morning, if they survive until then, when cul- 
tures and smears are made from the peritoneal cavity and 
the heart's blood under aseptic precautions. 

For cultural purposes a special glucose-blood broth is 
employed as recommended by Avery. 15 This is a meat- 
infusion broth, 0.3 to 0.5 per cent, acid to phenolphthalein, 
to which the requisite amount of glucose solution and of 
blood is added when needed, the three components being 
meanwhile kept separately in the ice-box, as suggested by 
Vaughan. 16 The broth is conveniently put up in lots of 100 
c.c. each and sterilized on three consecutive days, for twenty 
minutes at a time, in an Arnold steam sterilizer. The glucose 
solution is one of 20 per cent, and conveniently prepared by 
autoclaving distilled water in 50 c.c. lots., and then adding 
10 grams of chemically pure glucose to each lot, which is 
subsequently sterilized by boiling. 

Sterile defibrinated blood may be obtained, as suggested 
by Vaughan, by withdrawing from 20 to 30 c.c. of blood from 
an arm vein of a normal subject, or at any rate from one not 
suffering from a bacterial infection, and placing this in a 
sterile bottle containing some sterile glass beads. The blood 
is immediately shaken and then kept on ice. 

I have found it convenient to use sterile blood sent in for 
Wassermann examination for work of this kind. But little 
is really needed for the Wassermann test, and the remainder 
I stir up with a sterile glass rod and then transfer the liber- 
ated corpuscles together with the serum to a small flask, 
which is placed on ice. 

In the absence of human blood rabbit blood may be used. 

Immediately before use small test-tubes are then charged 
with 5 c.c. of broth and 0.25 c.c. of glucose solution and of 
blood each, so that the final product contains 1 per cent, 
glucose and 5 per cent, of blood. 



RECOGNITION OF THE PNEUMOCOCCUS CARRIERS 171 

One or more tubes of this culture medium are inoculated 
from the peritoneal cavity and the heart blood of the infected 
mouse and then incubated at 37° C, overnight. At the same 
time it is advisable to smear a blood-agar plate directly — 
partly with the peritoneal fluid, partly with the mouse's 
heart blood, so that the pneumococcus may be obtained in 
pure culture, should other organisms be present at the same time. 

A direct examination of suitably stained smears will usually 
indicate at once whether other organisms are present besides 
capsulated diplococci, for which we are in search. The fol- 
lowing day we may then proceed with the examination of 
the cultures that have been obtained in the special medium, 
providing that microscopic examination has shown that no 
other organisms are present. Otherwise subcultures will have 
to be prepared from the blood agar plates, in the same 
medium, and allowed to grow out. If the culture is pure the 
tube is centrifugalized for a couple of minutes at low speed 
to throw down the red cells, when the supernatant fluid may 
be subjected either to the precipitation or the agglutination 
test as follows: 

Precipitin Test. — The turbid bacterial emulsion is trans- 
ferred to a tube containing 1 c.c. of sterile ox bile and incu- 
bated at 37° C. for about twenty minutes. If the culture 
was pure the turbidity will clear up, owing to the dissolution 
of the pneumococci in the bile. If it has not cleared entirely 
the specimen is centrifugalized at high speed until every trace 
of turbidity has disappeared. A series of small tubes is uow 
charged with 0.5 c.c each of the cleared culture and the cor- 
responding antisera. Type I serum is best used undiluted, 
as is also type II serum, while type III is diluted 1 hi 5. The 
results may be read in a few minutes and are sharp and dis- 
tinct, a turbidity resulting in the tube which contains the anti- 
serum corresponding to the type present. Should a positive 
reaction be obtained with type II serum an additional speci- 
men is put up with a 1 to 10 dilution of this serum. If now a 
negative reaction is obtained the inference is that the type 
was an atypical II while a positive reaction indicates type II 
proper. The presence of type IV is indicated if a negative 
result is obtained w T ith all three of the antisera. 



172 PNEUMOCOCCUS PNEUMONIA 

Instead of working with a culture of the organisms as 
just described, Blake suggests to wash out the peritoneal 
exudate from the mouse with 4 to 5 c.c. of sterile saline, 
and after centrif ligation to use the clear supernatant fluid. 23 

It has been suggested that type I, II or III may be asso- 
ciated with type IV in a person's mouth and that the pres- 
ence of the latter may obscure that of any one of the fixed 
types in the final test. But, as a matter of fact, there is no 
danger of confusion from this source if a mouse is used to 
begin with, as it has been conclusively established that in 
the body of the latter the dangerous types rapidly outgrow 
the less pathogenic type IV. 

Agglutination Test. — The agglutination test is performed 
in the same manner as the precipitation test, barring the use 
of bile, of course. After slowly centrifugalizing the culture, 
so as to throw down the red cells, but not the bacteria (two 
to five minutes at slow speed) the supernatant emulsion is 
pipetted off and placed in 0.5 c.c. portions in small tubes as 
above. The antisera are then added, well mixed with the 
emulsion, and the tubes placed in the incubator for about 
two hours. Agglutination is usually well defined already at 
the end of an hour, and one can then readily pick out the 
types by noting the tube in which the supernatant fluid is 
clearer than in the others. On shaking, moreover, it will 
be noted that the bacteria have gathered in fairly large floc- 
culi in the positive tube, while in the negative specimens 
this does not occur. At the end of two hours the specimens 
are taken out of the incubator and may be allowed to stand 
at room temperature for a while longer. In the absence of 
contaminating organisms the readings are then sharp and 
distinct. I have found it convenient to put up a fourth tube 
and to add to this 0.5 c.c. of a 10 per cent, solution of sodium 
taurocholate. The clearing of this serves as additional proof 
that we are actually dealing with the pneumococcus. 

Should a positive reaction be gotten with undiluted type II 
serum an additional specimen is put up with the same serum, 
diluted 1 to 10, and as in the case of the precipitin reaction, 
an atypical type II may be inferred if agglutination now does 
not occur, while this will take place, of course, in the presence 



RECOGNITION OF THE PNEUMOCOCCUS CARRIERS 173 

of type II proper. As in the precipitin test, antiserum I is 
used undiluted, and serum III diluted 1 in 5. 

Type Determination in Sputa. — If for any reason it should 
be desired to study types of pneumococci in a sputum coming 
from the lung, the same method may be employed as 
described above, or we may resort to the abbreviated method 
of Avery-Vaughan, which will furnish a positive result within 
a day. The prerequisite of success is that the sputum actually 
does come from the lung. Unless this is assured the abbre- 
viated method is not applicable, and in such a case the initial 
isolation of the pneumococci must be conducted with the aid 
of the mouse. To secure a proper specimen of sputum it is 
recommended to collect what is first coughed up on awaking 
and after rinsing the mouth with sterile saline. In the case 
of a pneumonia patient it will be found that a fit of coughing 
will be started if he attempts to lie on his unaffected side. 
This usually terminates in the expectoration of one mass of 
sputum, which is quite sufficient for examination. The speci- 
men is immediately brought to the laboratory and placed in 
the ice-box if it cannot be examined at once, which latter 
is preferable, as the sputa are very apt to undergo autolysis 
even in the ice-box. The thickest portion of the sputum is 
then taken and a kernel, the size of a bean, washed in three 
or four changes of sterile saline in sterile dishes. The speci- 
men is then transferred to a tube of blood-glucose-bouillon 
(prepared as described above), taking care that it does not 
adhere to the sides of the tube, but is immersed altogether 
in the culture fluid. Avery recommends that the specimen 
after washing be first ground in a small sterile mortar with 
0.5 to 1 c.c. of broth and then transferred to the culture 
tube. This, however, is not necessary and is inconvenient 
if a number of specimens are to be examined at one 
time. 

The specimen is then incubated for five hours in a water- 
bath at 37° C, at the expiration of which time a sufficiently 
rich emulsion of organisms is usually available to conduct 
either the precipitin or the agglutination test as one desires. 
At the same time streak cultures are made on blood-agar 
in order to secure absolutely pure cultures, with which the 



174 PNEUMOCOCCUS PNEUMONIA 

requisite tests can be repeated if this is thought to be 
desirable. 

The precipitin test and the agglutination test are conducted 
as described above, preference being given the former if the 
cultures on microscopic examination are found to contain 
other organisms besides pneumococci. 

Contamination with saliva or the secretions from the 
pharynx or posterior nares is, of course, very apt to give rise 
to erroneous results, and lead to a type IV diagnosis when the 
organism in the deeper air passages was in reality of a dif- 
ferent type. In the artificial mouse, as the culture medium 
of Avery has been termed, the different types would, of course, 
grow side by side, and it is hence desirable before diagnosing 
type IV either to repeat the examination with a specimen of 
sputum that has been selected with special care, or to resort 
to mouse inoculation. 

Krumwiede's Method. M — This is based upon the extraction 
with saline of the precipitable substance contained in the 
pneumococci in sputum after coagulation of the associated 
albumins, which is then followed by the application of the 
precipitin test to the extract. The advantages claimed for 
the method are its simplicity and the fact that, given a proper 
specimen of sputum, a determination of the type can be 
made in one-half to one hour after the receipt of the specimen. 
For carrier diagnosis the method is, however, not applicable, 
as the sputum specimens which can be secured from conva- 
lescent pneumonia patients and passive carriers never con- 
tain pneumococci in sufficient numbers to yield an antigen 
directly that would be strong enough to give a visible reaction 
with the corresponding antisera. It may serve, however, for 
determining the type of the infection during the active period 
of the malady. Its limitations are the same as those which 
apply to the precipitation method as described above. In 
doubtful cases it should be supplemented by Avery's method 
or by the animal experiment. 

Technic. — From 3 to 10 c.c. of the sputum, depending on 
the amount available, are poured from the sputum container 
into a test-tube. This is placed in boiling water for several 
minutes or longer until a more or less firm coagulum results, 



RECOGNITION OF THE PNEUMOCOCCUS CARRIERS 175 

which will occur if the specimen is a suitable one. The coagu- 
lum is then broken up with a heavy platinum wire or glass 
rod, and saline is added. Just enough saline should be added 
so that, on subsequent centrifuging, there will be sufficient 
fluid to carry out the test. If too much is added, the resulting 
antigen may be too dilute. In some instances little or no 
saline is necessary, as sufficient fluid separates from the 
coagulum. 

After the addition of the saline, the tube is again placed 
in boiling water for a few minutes to extract the soluble 
antigen from the coagulum, the tube being shaken several 
times during the heating. The broken clot is then thrown 
down by centrifuge, and the clear supernatant fluid used for 
the test. To hasten the appearance of the reaction and to 
obtain a reaction even should the antigen be dilute, we layer 
the antigen over the "type" serums, using the latter undi- 
luted. Two-tenths c.c. of the three " type " serums are placed 
in narrow test-tubes, and the antigen added from a capillary 
tube with a rubber teat. If the tubes containing the serum 
are tilted and the antigen dropped slowly on the side of the 
tube just above the serum, no difficulty will be encountered 
in obtaining sharp layers, as the undiluted serum is suffi- 
ciently higher in its specific gravity. The tubes are then 
placed in the water-bath at from 50° to 55° C. and observed 
after several minutes. 

If a fixed type was present in the sputum, and should the 
sputum have been rich in antigen, a definite contact ring is 
seen in the tube containing the homologous serum. With 
sputums less rich in antigen, the ring may develop more 
slowly, and it will be less marked, Some experience is 
necessary in detecting the less marked contact rings and in 
differentiating them from an apparent ring which may be 
confusing, if one of the serums is darker in color, giving 
thus a sharper contrast with the supernatant antigen. The 
true ring is more or less opaque, and this quality can be seen 
by tilting the tubes and looking at the area of contact against 
a dark background; for example, the lower edge of a dark 
shade raised to just above the level of the eyes. The advan- 
tage of the ring test is that a ring may be evident, whereas 



176 PNEUMOCOCCUS PNEUMONIA 

definite clouding or a visible precipitate may appear only 
after longer incubation, or may be so slight even after an 
hour's incubation as to leave one in doubt. It is well to 
shake the tubes after twenty minutes, as many of the speci- 
mens will show definite clouding or precipitates either at 
once or on further incubation, thus checking the ring read- 
ing. The final reading may be made in from ten minutes to 
one-half hour. 

Management of the Pneumococcus Carrier. — Quarantine. — 
As the passive pneumococcus carrier owes his fatal gift to 
the active carrier, it is clear that the management of the 
carrier problem must begin at the bedside of the patient. 
The latter should be isolated so far as possible from the 
remaining members of the household, and in a hospital, from 
the other patients of the ward. Special pneumococcus wards 
would seem to be indicated only if the types could be kept 
apart. Theoretically it would seem best to have a receiving 
ward in which the patient should be placed until the type of 
his pneumonia has been ascertained, and then to move him 
into a corresponding ward. Such an arrangement would 
suggest itself as a rational one for our military hospitals, 
where fairly large numbers of cases are likely to occur and 
where the danger from carriers is even greater than in civil 
communities. 

As it is scarcely possible to prevent sputum spray from the 
patient to become disseminated in his immediate surround- 
ings, and as the dust in the patient's room probably is more 
dangerous than immediate contact with the patient, a face 
mask should be worn by all those who have to do with his 
care. 17 Such a mask is now used in our military hospitals 
as a matter of routine, and will probably prove the most 
important single factor in preventing the development of 
carriers. For the same reason the liberal use of disinfectants 
would seem to be indicated in the sick room or ward, which in 
turn would mean that these be stripped of everything in the 
nature of hangings and carpets and in fact all non-essentials. 
The management of a patient along these lines is, of course, 
impossible in small quarters, and for this reason, if no other, 
the individual should be cared for in a hospital, the home 



MANAGEMENT OF THE PNEUMOCOCCUS CARRIER 111 

being in the meantime disinfected by the proper authorities. 
It is high time that people should realize that no progress 
in the eradication of this, the most fatal of our common acute 
infectious diseases, is possible unless suitable health laws be 
enacted and carried out. At present the activity of most 
health departments in our country amounts to nil, so far as 
the effective control of the disease in question is concerned. 
Up to the time of writing not a single law or ordinance has 
been enacted, so far as I have been able to ascertain, beyond 
the mere reporting of the cases — which itself is only called 
for here and there — which could in any sense be regarded as 
a definite step looking toward the conquest or even the partial 
control of pneumonia. So long as bacteriological examina- 
tions of pneumonia cases and their contacts are not made as a 
matter of routine; so long as adequate hospital facilities do 
not exist for their management; so long as pneumonia con- 
valescents are allowed to mingle with others irrespective 
of the fact that they may be carriers; so long as the carriers 
are not located and at least instructed regarding the menace 
which they represent to others, so long will pneumonia not 
only remain with us, but, to judge from present indications, 
will become an increasing menace as time goes on. It is 
perfectly clear from the work that has been done in our mili- 
tary hospitals that pneumonia is a disease that can be suc- 
cessfully combated, and unless similar efforts are promptly 
made by the health authorities of our civil communities it 
is high time that these should be gotten rid of and replaced 
by men who are efficient and who are capable and willing 
to perform those duties for which they are appointed. The 
first and most important step in this direction is the removal 
of all health departments from political control. 

As I have just indicated, suitable bacteriological control of 
pneumonia convalescents, contacts and resultant healthy carriers, 
will prove to be the sine qua non in any attempt to diminish 
the spread of pneumonia. Fortunately we are now in the 
possession of a practical technic for this purpose, and no 
time should be lost in putting to practical use our ability to 
recognize pneumonia carriers of the most dangerous types at 
any rate. 
12 



178 PNEUMOCOCCUS PNEUMONIA 

As the pneumococcus carrier, whether active or passive, 
is of peculiar danger to others, owing to the probable manner 
in which he infects, stricter rules will be necessary for his 
control than for typhoid carriers, for example, or even for 
diphtheria carriers, for here we at least have an effective 
antiserum with which to control the disease when once it 
has developed, whereas in connection with pneumonia we 
stand powerless before types II and III, and even with regard 
to type I its treatment with antiserum has not yet proved 
so satisfactory as to merit being called a curative one. 

For these reasons it is desirable that all individuals harbor- 
ing pneumococci of types I and II at any rate should either 
be quarantined altogether or their movements restricted in 
such a manner that they cannot endanger the lives of others. 
A coughing carrier should not be permitted to scatter his 
germs broadcast, to use the same drinking utensils and table- 
ware as others, to sleep in the same room or even in the 
same bed with others, to shake out his pocket handkerchief 
before proceeding to a sonorous emptying of his nose. But 
even the non-coughing carrier can hardly be regarded as a 
suitable companion or visitor for those who are naturally more 
prone to develop pneumonia than others, such as the aged 
and infirm, young children, patients suffering or convales- 
cent from other diseases, from operations and the like. 

Disinfection of Carriers. — Whether or not it is possible by 
medicinal means to prevent the development of the carrier 
state, or to shorten or to arrest it, when once it has become 
established, is not known. To judge from the failure of all 
such attempts in connection with carriers of other bacteria, 
the outlook is not promising. If the pneumococci were 
present only on the mucous surfaces of the upper respiratory 
tract or in the saliva, one might expect some good from the use 
of mouth washes and gargles, containing ingredients that 
have a definite pneumococcidal effect in the test-tube, such as 
ethyl hydrocuprein and other cinchonics, as has been sug- 
gested by Kolmer and Steinfeld. 18 If, however, their proper 
habitat is in the deeper structures it is evident that the infin- 
itesimal quantities of these substances which would come in 
contact only with those organisms that have found their 



MANAGEMENT OF THE PNEUMOCOCCUS CARRIER 179 

way to the free surfaces could hardly be effective. Kolmer 
and Steinfeld have thus far not tested their suggested method 
of treatment in actual cases, and merely recommended it on 
the basis of the well-known pneumococcidal activity of the 
cinchonics in the test-tube. The formula proposed for 
washing the mouth and gargling is the following : 

Ethyl hydro cuprein hydrochloric!, or quinine bisulphate . . 005 

Liquor thymolis* 5.0 

Aqua distillata ad 50.0 

A similar solution made up in undiluted Dobell's solution 
is suggested for douching or spraying the nose, or the sub- 
stance may be incorporated in a dental cream and used for 
cleansing the teeth. 

Management of carriers of Types III and IV. — While the 
foregoing remarks apply, of course, with special force to carriers 
of the two types of pneumococci, which are met with practi- 
cally only in active cases or their contacts, and which we have 
reason to look upon as purely parasitic types, viz., I and II, 
according to Dochez's classification, any pneumonia patient 
harboring type III should be treated and viewed in the same 
manner. But as type III evidently also occurs in a fair 
percentage of healthy individuals who have not all, at any 
rate, been in contact with corresponding active cases, and 
probably represents an organism which is facultatively 
parasitic or saprophytic, the question arises whether healthy 
carriers of this type also should be subjected to the same 
rigid regulations which we regard as imperative in the man- 
agement of types I and II. On the face of it this would indeed 
be impossible, as the number is far too large, and as there 
could be but little object in quarantining only the occasional 
case that we would meet with more or less accidentally. 
Bearing in mind, however, that this type, when it does pro- 
duce pneumonia, is responsible for the highest death-rate, 
i. e., some 60 per cent., it stands to reason that an attitude 

* The liquor thymolis has the following composition: Benzoic acid, 64 
grains; boric acid, 128 grains; thymol and menthol, aa 16 grains; oil of 
eucalyptus, of wintergreen and monarda, aa 4 drops; alcohol and glycerine, 
aa 4 ounces; water sufficient to make up 16 ounces. 



180 PNEUMOCOCCUS PNEUMONIA 

of indifference toward such carriers is scarcely warrantable. 
The least that we can do is to keep such carriers under a cer- 
tain supervision and to instruct them how to avoid, so far 
as possible, the infection of others. Steps should further 
be taken to study thoroughly the extent to which this organ- 
ism is found in human beings and their environment, with- a 
view of obtaining a possible clue to their relatively frequent 
presence in the mouths of apparently healthy individuals 
and to determine whether indeed they are facultative para- 
sites only. 

As regards type IV carriers, our knowledge is as yet too 
meager to warrant the laying down of any rules in reference 
to their management. Type IV, as I have pointed out, is 
represented by a heterogeneous lot of pneumococci, differing 
from the so-called fixed types, and is regarded as essentially 
a saprophyte, which can readily exist in the mouth of prac- 
tically any person, and which when it does cause pneumonia 
produces a relatively mild form of the disease. That this type 
also may at times become dangerous has, however, been 
abundantly demonstrated during the present epidemic of 
so-called influenza, where a considerable percentage of the 
complicating pneumonias with a high death rate has been 
found to be due to pneumococci of this order. As has been 
suggested, it is possible that these cases are really auto- 
descending infections, the path for their downward course 
having perhaps been opened by some other organism. If 
this view is correct, individuals harboring this type cannot 
be regarded as carriers in the sense in which the term is now 
generally used. They may be dangerous to themselves, but 
they are not dangerous to others. Whether this view is 
correct, however, remains to be seen. 

Protective Inoculation Against the Pneumococcus. — In view 
of the manifest difficulties which stand in the way of a success- 
ful control of pneumococcus carriers by quarantine, or their 
disinfection by therapeutic means, it is particularly gratify- 
ing to note that a certain degree of protection, at any rate, 
can be secured against pneumococcus infections by inocula- 
tion with a corresponding vaccine. While it is hardly to be 
expected that sterilization of the carrier can be effected in 



IXOCULATION AGAINST THE PXEUMOCOCCUS 181 

this manner, it is clear that a diminution in the incidence of 
the disease must in turn lead to a diminution in the number 
of carriers and that the desired result will thus be indirectly 
achieved. Experiments in this direction were first under- 
taken on a large scale by Sir Almroth Wright 19 in South 
Africa, in 1911 and 1912, among native workers in the mines. 
The results obtained at the Premier Mine were very encour- 
aging, as the death-rate among 17,000 inoculated men was 
only 6.89 per thousand, whereas among 6700 non-inoculated 
controls it was 17.72, both sets having been selected entirely 
at random. On the Rand, on the other hand, no material 
difference was noted between the two classes. 20 This incon- 
gruity in the results' Darling 21 attributed to the possibility 
that the vaccine used at the Premier Mine was made up 
from a different strain from that used on the Rand. As a 
matter of fact, nothing definite was known of the existence 
of different strains of pneumococci at that time, and it is 
interesting to note that Darling's prophetic suggestive has 
since been supplied with the necessary experimental basis. 
For, as we have seen, in 1913 Dochez and Gillespie, in the 
United States, and Lister, 22 in South Africa, showed that 
different strains of pneumococci actually do exist, and shortly 
after, the latter undertook active immunization of the workers 
in three large mines on this basis. The results were such as 
to leave no doubt that protection can be afforded in this 
manner, for it was found not only that there was a definite 
decrease in the incidence and mortality from pneumonia, 
but — and most important of all — that the diminution in the 
incidence corresponded to the type of the vaccine which was 
employed. At the Crown Mines no cases of the types against 
which the men had been vaccinated thus occurred during 
the nine months of observation. In commenting upon the 
value of inoculation of a large body of people in a community, 
Lister* very properly points out that in consequence of the 
lowered incidence of the disease the number of carriers also 
must be diminished, and that the non-inoculated portion of 
the community thus benefits as a result. 

* In preparing his vaccine Lister killed the organisms by the use of germi- 
cides, and not by heat. Three subcutaneous injections were given, each dose 
containing from seven to ten million cocci. 



182 PNEUMOCOCCUS PNEUMONIA 

In the United States vaccination against the pneumococcus 
on a large scale was first undertaken during the early part 
of the winter of 1917-18, when 12,519 men were vaccinated 
at Camp Upton. The results have been reported by Cecil 
and Austin. 23 The vaccine itself was made up from strains 
I, II and III. The inoculations were made subcutaneously 
at intervals of five to seven days, 3,000,000,000 (one of each 
kind) being given the first time, 6,000,000,000 (2 of each) 
the second time, 7,500,000,000 (3 each of types I and II and 
If of type III) the third time and the same dose the fourth 
time. The great majority of the men received three or four 
injections. The subsequent observation period unfortunately 
covers only ten weeks, but even during this short time a 
marked difference in the pneumococcus pneumonia incidence 
is discernible between the vaccinated and the non-vaccinated 
groups, which latter numbered 19,481. Among the vacci- 
nated men there occurred but a single case of type pneu- 
monia (I), and as this developed twenty-four hours after 
the first injection, it is reasonable to conclude that infection 
had already occurred before that time and that the case may 
therefore be eliminated. Among the non-vaccinated men, 
on the other hand, there occurred 26 cases of type pneumonia. 

It is interesting to note that the vaccination apparently 
also had a protective effect against type IV, for whereas 
only 6 cases of this order developed among the men who had 
received two or more injections (0.04 per cent.), there were 
33 among the controls (0.2 per cent.), giving a ratio of 1 to 5. 
While 6 of the 33, moreover, died (18 per cent.), all of the 
vaccinated men, recovered. 

Evidently there was a considerable degree of cross-protec- 
tion, which is interesting in itself, but even more remarkable 
is the fact that the vaccination afforded a marked protection 
against streptococcus pneumonia which was prevalent at the 
same time. The results which were here obtained will be 
discussed in the section on Streptococcus Carriers. 

The findings obtained at Camp Upton, by themselves, are, 
of course, too few to warrant any far-reaching conclusions, 
but taken in conjunction with those reported by Lister 
from South Africa they clearly indicate that at last a very 



BIBLIOGRAPHY 183 

definite advance has been made toward the conquest of this 
scourge than which none is more formidable in civilized 
lands. 1 

BIBLIOGRAPHY. 

1. Dochez, A. R., and Gillespie, L. J. : A Biological Classification of 
Pneumococci by Means of Immunity Reactions, Jour. Am. Med. Assn., 1913, 
vol. lxi, p. 727. 

2. Hanes, F. M.: An Immunological Study of Pneumococcus Mucosus, 
Jour. Exp. Med., 1914, vol. xix, p. 38. 

3. Avery, O. T.: A Further Study on the Biological Classification of 
Pneumococci, ibid., 1915, vol. xxii, p. 804. 

4. Neufeld: Cited by Dochez and Avery (7). 

5. Schottmuller, H.: Munchen. med. Wchnschr., 1903, \ol. 1, p. 909. 

6. Lister, F. S.: Specific Serological Reactions wi b the Pneumococci 
from Diffeient Sources, Publication of the South African Institute for Med. 
Research, 1913, No. II. 

7. Doche2, A. R., and Avery, O. T.: Varieties of Pneumococcus and 
Lobar Pneumonia, Jour. Exp. Med., 1915, vol. xxi, p. 114. 

8. Idem., Carriers of Disease-producing Types of Pneumococcus, ibid., 
1915, vol. xxii, p. 105. 

9. Stillman, E. G.: A Contribution to the Epidemiclogy of Lobar 
Pneumonia, ibid., 1916, vol. xxiv, p. 651. 

10. Idem., Further Studies on the Epidemiology of Lobar Pneumonia, 
ibid., 1917, vol. xxvi, p. 513. 

11. Olmstead, M.: Types of Pneumococci Found in the Mouths of 
Surgical Cases before Operation, Pioc. Soc. Exper. Biol, and Med., 1918, 
vol. xv, p. 83. 

12. Le\y, R. L., and Alexander, H. L.: Results of Separation of Carriers 
from Non-carriers at a Base Hospital, Jour. Am. Med. Assi ., 1918, vol. Ixx, 
p. 1827. 

13. See 10, p. 523. 

14. See 19, p. 533. 

15. Avery, O. T. : Determination of Types of Pneumococci s in Lobar 
Pneumonia, Jour. Am. Med. Assn., 1918, vol. Ixx, p. 17. 

16. Vaughan, W. T.: Type Determination of Pneumococcus Infection, 
ibid., p. 431. 

17. Capps, J. A.: The Face Mask in Control of Contagious Diseases, 
Jour. Am. Med. Assn., 1918, vol. Ixx, p. 910. See also: Weaver, G. H.: The 
Value of the Face Mask, ibid., p. 26; Haller, D. A., and Colwell, R. C. : The 
Protective Qualities of the Gauze Face Mask, ibid., vol. lxxi, p. 1213; and 
Doust, B. C, and Lyon. A. B.: Face Masks in Infections of the Respiratory 
Tract, ibid., p. 1216. 

18. Kolmer, J. A., and Steinfeld, E.: The Disinfection of Pneumococcus 
Carriers, Jour. Am. Med. Assn., 1918, vol. Ixx, p. 14. 

1 During the recent epidemic of so-called influenza the United States 
Army made use of a triple pneumococcus vaccine on a large scale for pro- 
phylactic purposes, in view of the fact that most of the fatalities from the 
disease were due to the action of pneumococci, but up to the time of writ- 
ing no data are available from which conclusions can be drawn. 



184 



■PNEUMOCOCCUS PNEUMONIA 



19. Wright, A. E.: Observations on Prophylactic Inoculation Against 
Pneumococcus Infections, Lancet, 1914, i, p. 87. 

20. Gorgas, W. C: Recommendations as to Sanitation Concerning 
Employees of the Miners on the Rand, Jour. Am. Med. Assn., 1914, vol. 
lxii, p. 1855. 

21. Cited by Gorgas (20), p. 1858. 

22. Lister, F. S.: An Experimental Study of Prophylactic Inoculation 
Against Pneumococcal Infection in the Rabbit and in Man, Publication 
of the South African Institute for Medical Research, 1916, No. 8. Idem, 
Prophylactic Inoculation of Man Against Pneumococcal Infections, and 
More Particularly Against Lobar Pneumonia, ibid., 1917, No. 10. 

23. Blake, F. S.: Method for the Determination of Pneumococcus Types, 
Jour. Exp. Med., 1917, vol. xxvi, p. 67. 

24. Krumwiede, C, Jr., and Valentine, E.: Determination of the Type 
of Pneumococcus in the Sputum of Lobar Pneumonia, Jour. Am. Med. 
Assn., 1918, vol. lxx, p. 513. 

25. Sydenstricker, V. P. W., and Sutton, A. C: An Epidemiological 
Study of Lobar Pneumonia, Johns Hopkins Hosp. Bull., 1917, vol. xxviii, 
p. 306. 

26. Clough, M. C: A Study of the Incidence of the Types of Pneu- 
mococci, Isolated from Acute Lobar Pneumonia and Other Infections, etc., 
ibid., 1917, vol. xxviii, p. 306. 

27. Hartmann, C. C, and Levy, G. R. : The Biological Classification in 
Pneumococci Infections, Jour. Am. Med. Assn., 1917, vol. lxix, p. 2165. 

28. Valentine, E.: Common Colds as a Possible Source of Contagion 
for Lobar Pneumonia, Jour. Exp. Med., 1918, vol. xxvii, p. 26. 



STREPTOCOCCUS INFECTIONS. 

Camp Septicemia, Bronchopneumonia, Septic Sore 
Throat, Puerperal Fever, etc. 

The question as to whether or not the forms of strepto- 
coccus infection, and more particularly those which have a 
tendency to appear in epidemic form, such as our common 
winter colds or grippes, are disseminated by human carriers 
of the type which we are principally considering in these 
pages has until recently been largely a matter of conjecture. 
The principal difficulty which has stood in the way of a satis- 
factory solution of the problem has been our inability to 
differentiate those organisms belonging to the streptococcus 
family, which are met with in the corresponding lesions from 
the streptococci wdrich may be cultivated from supposedly 
any so-called normal individual's throat or mouth. We have 
tactily and, no doubt, properly assumed that a streptococcus 
which we meet with in an acutely inflamed antrum, or middle 
ear, or mastoid, or in deposits on acutely inflamed tonsils, 
or as the predominating organism in the sputum of cases of 
bronchitis or in connection with the bronchopneumonia of 
old people, is the organism that is actually responsible for 
the associated lesions. But unfortunately we have not been 
able to state when finding apparently identical organisms in 
the throats of healthy individuals whether these were in 
reality identical w T ith the former, and it is clear that unless 
we are able to prove this identity we have no right to assume 
it, and we could not accordingly declare that this or that 
person is a carrier of a type of streptococcus that under suit- 
able conditions is capable of producing a certain clinical or 
pathological anatomical picture. So long as we were unaware 
of the existence of distinct types of pneumococci and their 
exclusive occurrence in certain cases of lobar pneumonia dur- 



186 



STREPTOCOCCUS INFECTIONS 



ing the active stage and the convalescence from the disease, 
and in individuals who have been in more or less intimate 
contact with such cases, we could not rightfully speak of 
pneumococcus carriers in the sense in which the term is 
now employed. It was long known that pneumococci 
exist in the mouths of from 50 to 80 per cent, of healthy 
individuals, and it was assumed that when pneumonia did 
develop it was essentially an auto-infection, but the proof 
that the latter is not the case in the majority of cases 
could only be furnished when we had come to recognize 
that different types of pneumonia exist and to learn to differ- 
entiate these from each other. For the assumption that the 
disease was largely disseminated by carriers there was form- 
erly, indeed, very little epidemiological evidence, as contact 
cases of pneumococcus pneumonia are after all infrequent. 
In the case of the streptococcus infections, on the other 
hand, to which I have referred above and which occur 
with such constancy winter after winter, we have sufficient 
circumstantial evidence to assume, that their dissemination 
takes place either through direct or indirect contact. But, 
as I have said before, we have unfortunately not been able 
to furnish the requisite bacteriological proof, owing to our 
inability to distinguish between pathogenic and non-patho- 
genic types, if indeed there be such types, and the pathogenic 
properties be not of a temporary nature only. It is true we 
recognize a Streptococcus viridans, a Streptococcus hemo- 
lyticus and a Streptococcus mucosus, but in view of our lack 
of knowledge concerning their pathogenicity and their fre- 
quent occurrence in the throats of healthy individuals we 
have not been in a position where we could designate anyone 
harboring these organisms as a carrier, meaning thereby a 
potential disease-producing agent. We know that a Strep- 
tococcus viridans has a special affinity for serous membranes, 
that a Streptococcus mucosus has a tendency to invade lym- 
phatic structures and that a Streptococcus hemolyticus is 
frequently found in connection with "grippal" bronchitis 
and "grippal" pneumonia, but, as I have said before, we do 
not know whether these particular types are identical with 
those encountered in the throats of healthy persons. 



CAMP SEPTICEMIA AND BRONCHOPNEUMONIA 187 

Camp Septicemia and Bronchopneumonia. — Our knowl- 
edge of these matters has, however, .been greatly increased 
through the splendid series of studies that have been carried 
on during the winter of 1917-1918 in connection with the 
epidemic of streptococcus infections and notably of strepto- 
coccus pneumonias which occurred in certain camps of our 
national army. The course of this epidemic and its relation 
to carriers was practically the same in all cases, and is well 
exemplified by the experience gathered at Camp Zachary 
Taylor, Ky., as related by Hamburger and Mayers, 1 Fox and 
Hamburger 2 and Levy and Alexander. 3 At this camp pneu- 
mococcus pneumonia appeared early in the autumn of 1917 
and continued at the rate of about 50 cases a month through- 
out the winter. Streptococcus infections began to occur 
quite early also, and the same was true of measles. It is 
noteworthy that almost from the start the streptococcus 
infections showed a great diversity in their local manifesta- 
tions. In some of the measles cases bronchopneumonia 
developed, but mortality from this at first was about what 
would be expected in measles occurring among adults in civil 
communities. Very soon, however, there became noticeable 
a marked increase not only in the incidence of streptococcus 
infections, but also in the severity and types of the cases. 
While the epidemic in question was by no means confined 
to the measles cases, and was very properly regarded as sepa- 
rate from the measles epidemic, these patients evidently not 
only offered the least resistance to the infection but proved 
a peculiarly favorable soil, so that complications of every 
conceivable nature became only too common. Of these, 
bronchopneumonia, with a remarkable tendency to empyema, 
was the most frequent and the most fatal (47 per cent. — 
Cole). 

Bacteriological investigations revealed the presence of a 
hemolytic streptococcus in the corresponding lesions. In the 
bronchopneumonia cases this organism was found in the 
blood, in the sputum and in the lungs, mostly in pure cul- 
ture, but occasionally associated with a bacillus which Cole 4 
regarded as the influenza bacillus. The relation of the latter 
to these cases is not clear, bat in all likelihood it is of a 



188 STREPTOCOCCUS INFECTIONS 

secondary nature. The conclusion which was reached by the 
commission sent out by the Surgeon-General 4 was that the 
hemolytic streptococcus in question was the causative agent of 
the epidemic. 

In investigating the origin of the epidemic, and particu- 
larly the manner of infection in the measles cases, it was ascer- 
tained by the Surgeon-General's Commission, at Fort Sam 
Houston, that of 69 measles cases 39, i. e., 56.5 per cent., 
harbored a hemolytic streptococcus in the throat. 

In view of the fact that certain observers have maintained 
that the presence of actively hemolytic streptococci is very 
rare in normal throats, 5 the question naturally arose whether 
this was true in the case of the military population at Fort 
Sam Houston. For purposes of comparison, cultures were 
therefore taken from the patients in a different ward, and one 
in which no measles cases were kept. To this end a ward 
was chosen in which the patients were suspected of having 
tuberculosis, but no other disease. It was found that although 
the percentage of patients harboring a hemolytic strepto- 
coccus was materially lower than in the measles ward, it was 
nevertheless fairly high, i. e., 21 A per cent. In two other 
wards, containing only patients who were thought to have 
lobar pneumonia, 57.7 per cent, were found to harbor these 
organisms. 

In order to ascertain whether the patients had acquired 
the hemolytic streptococcus before entering the wards or 
whether infection had occurred within, 44 measles patients 
were examined on admission, then again three to five days 
later, and again eight to sixteen days after admission. The 
resulting percentages of positive findings were 11.4, 38.6 and 
56.8. These figures speak for themselves and prove conclu- 
sively that infection in the majority of cases occurred after 
admission. The same conclusion was reached in a different 
manner by Levy and Alexander at Camp Zachary Taylor. 3 
In two of the measles wards non-infected and infected cases 
were placed in alternate beds, with the result that at the end 
of a week 66.6 per cent, of the originally clean cases now 
harbored the streptococcus in their throats. 

In order to ascertain whether the men who came to the 



CAMP SEPTICEMIA AND BRONCHOPNEUMONIA 189 

hospital already infected with hemolytic streptococci had 
acquired these in camp or before, throat swabs were taken 
from 489 recruits, representing both urban and rural com- 
munities, as they stepped from the train. Of these 14.8 per 
cent, showed the presence of hemolytic organisms — which, 
however, were not further identified. Corresponding studies 
which were made of a company of 95 men belonging to an 
organization to which all new men entering camp were 
attached during the early period of their training, showed that 
83.2 per cent, were infected, and it is noteworthy that of the 
388 measles cases that were examined, 346, i. e., 77.1 per cent., 
were found infected on admission. This is in striking con- 
trast to the figures given by Cole as prevailing at Fort Sam 
Houston. 

The conclusion that may be drawn from these studies is that 
the great majority of the recruits become infected through a 
relatively small percentage of supposedly healthy carriers, that 
of the infected, in turn, a certain number become carriers 
of this order, while others are rendered ill. In some of the 
latter the resultant malady is of a minor order, such as 
pharyngitis, tonsillitis, laryngitis, while in others more 
serious disturbances develop. Measles cases seem to furnish 
the most suitable soil for the development of the organism, 
in a manner quite analogous to the occurrence of puerperal 
fever and erysipelas on the introduction of pathogenic 
streptococci into a puerperal or a surgical ward. As the 
epidemic progresses the virulence of the organism is appar- 
ently increased, and at its height the clinical picture of a 
primary sepsis and serositis develops, frequently without any 
changes in the lungs, and resulting in an appalling death- 
rate. 

That healthy carriers, or carriers at any rate, who are 
not regarded as ill, are responsible for these outbreaks can 
scarcely be doubted, even though we are not in a position as 
yet to assert that a hemolytic streptococcus found in a throat 
of an apparently healthy person outside of an epidemic zone 
is capable of giving rise to disease in others. It is conceivable 
that the organisms which may be found in the throats of 
normal persons at times when no epidemic exists are non- 



190 STREPTOCOCCUS INFECTIONS 

pathogenic, and that they develop pathogenic properties only 
when they fall upon a special soil. On the other hand, we 
must remember that in large communities, at any rate, mala- 
dies due to streptococci are endemic, and that accordingly 
the carriers in question may in reality be carriers of organ- 
isms that are already pathogenic. Apart from our inability 
to distinguish between pathogenic and non-pathogenic strepto- 
cocci occurring in normal throats, there is the factor of the 
wide distribution of organisms of this order which makes us 
hesitate to speak of all individuals harboring such as carriers, 
exactly iu the same way as we hesitate to look upon persons 
harboring the pneumococcus IV as carriers. 

However this may be, so much is certain that some carriers 
of some hemolytic streptococci are a grave menace to others, 
and should be viewed in the same light as carriers of other 
disease-producing organisms. 

As I have said before, there are many gaps as yet in our 
knowledge regarding the relationship of some of the common 
mouth organisms to disease, but practically speaking the 
conclusion just formulated may stand. 

The experience gathered at Camp Zachary Taylor and at 
Fort Sam Houston corresponds in practically every detail 
to the findings obtained at the other army posts, as related 
by Duncan and Sailer, 6 Irons and Marine, 7 Cumming, 
Spruit and Lynch. 8 The studies of the latter are of especial 
interest in so far as they made an attempt to classify the 
hemolytic streptococci found, in accordance with the type of 
hemolysis that they produced. Their type I corresponds to 
the Streptococcus viridans hemolysis; types II and III to 
the alpha and beta types of hemolysis respectively of Smith 
and Brown. 9 A corresponding analysis of the findings 
obtained from the throat swabs of 291 measles patients on 
entrance to the hospital revealed that 187 showed type I 
and type II hemolysis, and that of these only 4 developed 
bronchopneumonia; but during this complication type III 
hemolytic streptococci in all 4 were isolated. 104 of the total 
number showed type III hemolysis and of these 34, i. e., 
33 per cent., developed bronchopneumonia. The writers 
state that 70 swab specimens from average throats showed 



CAMP SEPTICEMIA AND BRONCHOPNEUMONIA 191 

only 6 per cent, of hemolytic streptococci, which corresponds 
to the findings of Smillie, 10 obtained in civil life. But they 
do not indicate from what class of material their results were 
obtained. 

- Duration of the Carrier State. — Regarding the duration of 
the carrier state in convalescents from the camp epidemic 
under consideration, Levy and Alexander state that with rare 
exceptions the organisms persisted in the throat through- 
out the patient's entire stay at the hospital, and that on 
discharge 71.7 per cent, of all of the patients who had 
entered the measles wards still harbored the organisms in 
question, and were no doubt capable of infecting others, and of 
producing disease when and wherever the soil was favorable. 
Under the circumstances it can hardly be surprising that 
Irons and Marine 7 found 70 per cent, of all the men harboring 
hemolytic streptococci during the latter part of the period 
of acute respiratory infections (Camp Custer). 

Manner of Infection. — As regards the manner of infection 
there is, of course, a possibility of direct infection through 
sputum spray, but to judge from the experience gathered 
at the various camps there can be no doubt that infection 
through contaminated dust is probably the usual method. 
This is evidenced by the findings at Camp Zachary Taylor. 
The infected and non-infected measles cases were here sepa- 
rated, and the patients placed in cubicles formed by suspended 
sheets. When not in bed in their cubicles the patients were 
obliged to constantly wear gauze masks, which were changed 
every day. All attendants were gowned and likewise masked. 
But notwithstanding these precautions it was found that on 
placing non-infected cases in an infected ward and isolating 
them in cubicles they became infected nevertheless. The 
only medium through which infection could occur under the 
circumstances was the air, viz., the suspended dust. 

These findings demonstrate in the clearest manner possible 
not only the mode of infection, but also the amazing readiness 
with which the streptococcus in question was capable of 
obtaining a foothold. 

Habitat of the Organism. — The habitat of the organisms in 
the upper respiratory tract is as yet unknown, but we may 



192 STREPTOCOCCUS INFECTIONS 

well imagine that like other pathogenic organisms which gain 
access to the human body through the air, they probably 
lodge in the crypts of the tonsils and other nooks and corners 
connected with the lymphatic structures of this region. 

Mode of Invasion. — As to the manner in which the organ- 
isms invade the human body, different possibilities exist. In 
the measles cases where we usually have a more or less marked 
pharyngitis, laryngitis or bronchitis, it is quite conceivable 
that the complicating bronchopneumonia is the result of a 
descending infection. In the others there is probably always 
an initial lymphogenic infection, which in turn may lead to 
a generalized septicemia. 

Relation between Camp Epidemic Septicemia and the Ordi- 
nary Winter Infections Occurring in Civil Life. — An interesting 
question which arises in connection with the camp epidemic 
of the winter of 1917-1918 is whether the type of organism, 
which evidently was responsible for the outbreak, was also 
the cause of the coexistent winter infections — of non-pneumo- 
coccic nature — which prevailed in civil communities, not 
only then, but which appear in civil communities practically 
every winter. We have seen that the epidemic could be 
traced fairly definitely to healthy recruits coming from urban 
and rural communities; in other words, the infection was 
carried into the camps from without and did not primarily 
originate within the camps. If we accept this view, we must 
also concede that these same carriers, under favorable con- 
ditions, could have infected inhabitants of the communities 
from which they were drafted. Furthermore, we must con- 
cede that for every carrier who left his home there undoubt- 
edly must have been at least one carrier who remained at 
home. In other words, there is no reason for supposing that 
the percentage of carriers remaining was materially less than 
the percentage that left. That the remaining carriers in the 
course of the winter caused the infection of other individuals, 
and that some of the carriers fell ill themselves can scarcely 
be doubted, so that we unquestionably have the right to 
assume that many of the minor winter infections at any rate 
were due to the same type of carrier as the serious infections 
occurring in the camps, even though corresponding bacterio- 



CAMP SEPTICEMIA AND BRONCHOPNEUMONIA 193 

logical examinations were not made. Investigations in this 
direction are, of course, urgently needed to establish beyond 
question the proposition which I have just formulated, viz., 
that the camp epidemic in all its phases was in reality noth- 
ing else than the common type of winter infection which visits 
us practically every year, that the difference was practically 
only one of degree of virulence on the part of the organism, 
and that this in turn was brought to such a high point, owing 
to the crowding of the camps and the facilities thus afforded 
for a most extensive degree of " animal passage," in which 
the presence of a measles soil no doubt played an important role. 

This view is well supported by the fact that epidemics of 
this order were not confined to any special region, but 
occurred in practically every district of the United States. 
The fact that the disease was more prevalent in the Southern 
Department can no doubt be explained on the basis of local 
conditions. 

Relation of Camp Septicemia to Septic Sore-throat. — It has 
been suggested that the organism found in the camps is iden- 
tical with the one that has been encountered in connection 
with the various epidemics of so-called septic sore-throat which 
have occurred in the United States within recent years, and 
which have been traced to infection of the milk supply in 
every instance. Cumming, Spruit and Lynch 8 state directly 
that the hemolytic streptococcus in question is of universal 
prevalence, and has been isolated by them from cases of 
septic sore-throat in Massachusetts, on the one hand, and in 
Michigan on the other. They look upon it as the so-called 
human type which when transmitted to cows' udders by 
milkers is very apt to spread through the milk supply and 
thus give rise to epidemics of greater or less magnitude. 
While the identity of the organisms encountered under such 
conditions, with the Streptococcus hemolyticus found in camp 
septicemia, can hardly be regarded as proved, we can say 
at least that both conditions are due to the activity of a 
hemolytic streptococcus, and that carriers do play the same 
important role in the dissemination of so-called septic sore- 
throat, be this by infecting the milk supply of a community, 
or directly or indirectly through the air (sputum spray, dust). 
13 



194 STREPTOCOCCUS INFECTIONS 

In the course of his investigation of the Boston outbreak, 
during which 1400 persons were stricken and of which 1043 
were investigated, Winslow 13 found no evidence of cattle 
disease and no well-defined cases of sore-throat among the 
milkers. But as cases of sore-throat were encountered among 
other employees at the farm, he no doubt correctly concluded 
that actual infection of the milk supply had occurred through 
a carrier. To this inference the objection might be raised 
that no evidence of mastitis was found among the cattle. 
But as Davis 14 subsequently demonstrated experimentally, 
an ascending infection of the teat and udder may take place 
through a slight abrasion of the skin by the contaminated 
hand in the act of milking, without producing any evidence 
of so-called caking of the bag. We can accordingly well 
understand how Winslow may have overlooked the existence 
of mastitis among the cows, even though the demonstration 
of the organisms in the milk showed this to have been 
infected. As the milkers themselves showed no evideuce 
of sore-throat, the inference that one or another of these was 
a carrier is the only possible conclusion that could be reached. 

In his investigation of the Baltimore outbreak, during 
which 1000 persons were stricken, Stokes 15 traced the infection 
to a definite herd, but also could not locate the infected cow. 
There was no history of septic sore-throat among the farmers 
and employees, but systematic bacteriological studies were 
not made. I myself had occasion to study a number of cases 
during this epidemic and found that the organism in question 
was capsulated — which accords with the results obtained by 
others, and shows that this particular type of streptococcus 
at any rate differed from that which has been shown to be 
responsible for camp septicemia. In the Chicago epidemic 
of 1913, during which 10,000 cases of septic sore-throat 
developed, Rosenow 16 obtained the "streptococcus pyogenes " 
directly from the inflamed udder of a cow, and also from the 
throat of a milker who was suffering with sore-throat, while 
septic sore-throat existed among other employees. 

The Role of Streptococcus Carriers in the Dissemination of 
Puerperal Fever and Erysipelas finally has been so well estab- 
lished, by circumstantial evidence, it is true, that even in the 



CAMP SEPTICEMIA AND BRONCHOPNEUMONIA 195 

absence of bacteriological proof, no reasonable doubt can 
remain. The connection may be capable of ultimate bac- 
teriological proof in isolated cases, even under existing con- 
ditions, but a final verdict will in many cases only be possible 
when once our knowledge of streptococcal strains has 
advanced to a point where such strains can be definitely 
recognized and their properties foretold in the laboratory. 
So far as our present knowledge goes we are unable to dis- 
tinguish between a streptococcus capable of causing erysipe- 
las and one causing puerperal fever, nor can we distinguish 
such organisms from those found in camp septicemia or in 
some cases of septic sore throat. Whether any differences 
exist is indeed a question, and it is not improbable that future 
studies will show that there is but one type of streptococcus 
pathogenic for human beings, and that the diversity of lesions 
is not so much, if at all, due to specific properties on the part 
of the organism as to differences in the nature of the sub- 
stances, i.e., the tissues that are attacked. 

The Recognition of Streptococcus Carriers. — In view of our 
imperfect knowledge of streptococcus strains, and above all 
in view of our inability to foretell, in the laboratory, the 
virulence and the specific pathogenic properties of organisms 
belonging to this group, we are obliged to confine our account 
of the recognition of streptococcus carriers to a considera- 
tion of those gross types which have been found in connection 
with definite pathological anatomical conditions. The term 
streptococcus after all is a purely morphological term, and 
presages nothing regarding the biological, let alone the patho- 
genic, properties of the organism. For some time the strepto- 
coccus family was divided into two groups, according to the 
length of the chains; a Streptococcus longus and brevis was 
accordingly spoken of. It goes without saying that such a 
classification was warrantable as much as would be a divi- 
sion of human beings into such with long legs and others 
with short legs. In 1903 Schottmuller 11 proposed the classi- 
fication of the streptococci found in connection with lesions 
occurring in the human being according to the appearance 
of their colonies upon human blood agar. He thus recognized 
two groups, viz., one producing hemolysis on this medium — 



196 STREPTOCOCCUS INFECTIONS 

Streptococcus hemolyticus — while the other formed green, 
non-hemolyzing colonies — Streptococcus viridans. In addi- 
tion to these a third type was recognized, which is charac- 
terized by the constancy with which it forms large capsules, 
thus resembling the pneumococci. Further studies have 
shown that most of the organisms of this latter group are 
bile soluble and ferment inulin, and for this reason, as well 
as the fact that corresponding organisms have been found in 
certain cases of lobar pneumonia, this type is now looked 
upon as a pneumococcus and not a streptococcus, and is 
termed pneumococcus mucosus capsulatus . 12 Occasional 
strains are, however, at times met with which neither fer- 
ment inulin nor are bile soluble and which may possibly 
represent a separate group to which the term Streptococcus 
mucosus capsulatus should be confined. Of the group as a 
whole, which evidently stands between the streptococci in 
the old sense of the term, it is said that its members rarely 
cause hemolysis, but it should be borne in mind that the 
organism which has been found in septic sore throat has been 
described as a hemolytic capsulated streptococcus. From 
these data in themselves it is clear that this classification also 
is not satisfactory. The same may be said of that proposed 
by Smith and Brown, 9 on the basis of the types of hemolysis 
which the organisms produce. 

More recently Kinsella and Swift 18 have studied large num- 
bers of strains of both hemolytic and non-hemolytic strepto- 
cocci on the basis of their immunological reactions, and 
have found that whereas no two of the non-hemolytic strains 
behaved in an identical manner, the hemolytic variety is 
homogenous, consisting of members that are nearly identical. 
This discovery represents real progress in our knowledge of 
this group of organisms, and constitutes a promising basis 
upon which future studies may be carried on. 

Demonstration of the Streptococcus Hemolyticus in Carriers. 
— Swab cultures are made, on blood agar plates, from the 
pharynx and tonsils of the individuals to be examined, and 
incubated for twenty-four hours. Pneumococcus colonies 
will then appear surrounded by a narrow greenish zone of 
discoloration, which is due to a slight degree of hemolysis, 



CAMP SEPTICEMIA AND BRONCHOPNEUMONIA 197 

associated with methemoglpbin formation. This type Smith 
and Brown refer to as type I hemolysis. Streptococcus viri- 
dans on the same medium produces green, non-hemolyzing 
colonies resembling those of the pneumococcus. The Strep- 
tococcus hemolyticus, on the other hand, produces a very 
distinct zone of hemolysis, measuring from two to three milli- 
meters in diameter. This type of hemolysis has been sub- 
divided into an alpha and a beta type, which Smith and 
Brown refer to as types II and III. Type III according to 
Cumming, Spruit and Lynch represents the Streptococcus 
hemolyticus with which we have been especially concerned 
in the foregoing pages. 

Streptococcus mucosus finally causes hemolysis of the same 
type as Streptococcus hemolyticus. Attention is directed to 
it on the plate by its growth in large mucoid colonies. 

In order to definitely identify the Streptococcus hemo- 
lyticus hemolyzing colonies are now fished and studied in 
pure culture in reference to their cultural characteristics, the 
morphology, the staining reaction, the bile solubility, and 
fermentative and hemolytic activity of the corresponding 
organisms. 

Their hemolytic activity is tested by adding to a given volume 
of a twenty-four-hour bouillon culture an equal volume of a 
5 per cent, emulsion of the red cells of a rabbit or sheep, 
and noting the degree of hemolysis after incubating for two 
hours at 37° C. 

Bile solubility is tested by adding sterile rabbit or ox bile* 
to a twenty-four-hour growth in bouillon in the proportion 
of 0.1 c.c. of the former to 1 or 2 c.c. of the latter, and incu- 
bating for half an hour at 37° C. At the end of that time a 
pneumococcus culture will have cleared, while a streptococcus 
culture remains turbid. In the absence of bile a sterilized 
10 per cent, solution of sodium taurocholate or sodium glyco- 
cholate in normal salt solution may also be employed, and 
used in the proportion of 1 to 5, or 1 to 10 of the cultures. 



* This is prepared as follows: The bile is obtained at the slauphter house, 
autoclaved for twenty minutes at fifteen pounds' pressure, filtered and again 
autoclaved, after which it is ready for use. 



198 STREPTOCOCCUS INFECTIONS 

Identification of the Streptococcus Mucosus. — The strepto- 
coccus mucosus is identified by its tendency to grow in large 
mucoid colonies on the blood-agar plate on which it produces 
zones of hemolysis similar to those of the Streptococcus 
hemolyticus. The organism is, however, capsulated, the 
individual cocci being in close apposition and presenting 
rounded ends. It does not ferment inulin and twenty-four- 
hour cultures in broth manifest no solubility upon the addi- 
tion of bile, no are they agglutinated by antipneumococcus 
serum — type III — which clumps the corresponding pneumo- 
coccus, with which Streptococcus mucosus has been confused 
in the past. 

Preparation of Hiss's Serum Water Media. — The serum 
water is prepared as described in the section on meningitis 
and heated for fifteen minutes at 100° C. in an Arnold steam 
sterilizer and then treated with approximately 1 per cent, of 
a 5 per cent, aqueous solution of litmus (sufficient to impart 
a deep transparent blue color) and 1 per cent, of the various 
sugars, after wrrch the media are sterilized in the Arnold 
sterilizer — at 100° C. — for twenty minutes on three consecu- 
tive days. 

To prepare the inulin medium the inulin is dissolved in 
water, autoclaved at fifteen pounds for fifteen minutes, in 
order to kill spores, and then added to the requisite amount 
of serum, after which the mixture is sterilized fractionally 
as above. The inulin tubes should be observed for at least 
forty-eight hours before being read. The pneumococci will 
cause the cleavage of the substance with resultant acid forma- 
tion, which leads to coagulation of the serum and reddening 
of the litmus. Streptococci do not produce this result. 

Management of Streptococcus Carriers. — Quarantine. — 
From what we have learned regarding the rapidity and the 
extent to which the carrier state is apt to develop in the 
course of an epidemic, it is manifest that the control of the 
carrier by quarantine is practically out of the question, and 
any attempt in this direction may from the very start be 
regarded as fruitless. We have seen that in certain depot 
brigades fully 80 per cent, of the soldiers were infected, and 
I have pointed out that fully 70 per cent, of the cases admitted 



CAMP SEPTICEMIA AND BRONCHOPNEUMONIA 199 

to the hospitals were still carriers when discharged, so that 
we may assume that it is only a question of time when an 
entire camp will become infected. We should accordingly 
be obliged to begin with the process of quarantining before 
the recruits enter the depot brigades. But as 12 per cent, 
of these arrive at the camp already infected, it is clear that 
the entire organization would be rendered ineffective if 
such a number of men were withdrawn at the very outset 
of their military training. The same, of course, holds true 
for civil life, the difference being merely a question of a 
further increase in the difficulty of handling the situation. 
In a military community the problem could at least be solved 
in principle, while in civil life even this would be out of the 
question. 

The problem then is what to do. The only alternative 
proposition evidently is that we attempt to keep away from 
carriers those w T ho, according to our present knowledge, 
would be most likely to suffer if by chance they should become 
infected. This would mean the isolation of the old and the 
infirm, for example, from individuals who are evidently 
suffering from a respiratory disturbance associated with 
sneezing, coughing and hawking, the introduction of the 
face mask not only into the hospital but also into the private 
home. In military communities no patient should be per- 
mitted to enter a ward containing clean surgical cases or into 
a ward containing clean measles cases without a previous 
bacteriological examination. Xo attendants should be per- 
mitted in these wards who are carriers, and those whose duty 
it is to visit both clean and dirty wards should be freshly 
gowned, capped and masked. The isolation of susceptible 
individuals should be continued until their health has been 
sufficiently restored as to render the occurrence of dangerous 
complications or sequelse unlikely. In military hospitals the 
cubicle system should be employed altogether in those wards 
in which susceptible patients are confined, but the isolation 
should be carried out more completely than is possible by the 
sheet method alone. 

In civil communities the hospitalization of all measles 
cases wxmld, of course, be the ideal plan, the patient being 



200 STREPTOCOCCUS INFECTIONS 

first placed in a detention ward until the necessary bacterio- 
logical examination can be made, after which he would be 
transferred to a clean or dirty ward, as the case may be. In 
this manner the spread of measles not only would be curtailed, 
but also the dissemination of hemolytic streptococci whose 
virulence is increased through measles passage. In the case 
of the well-to-do, transfer to a hospital, it is true, might not 
be necessary, but its many advantages in the case of the poor 
are so obvious as to require no further discussion. 

Exclusion of. Carriers from Food Supply. — That an indi- 
vidual who is suffering from a streptococcus infection should 
not be permitted to handle or prepare certain articles of 
food goes without saying, and it would follow that he should 
be excluded from such an occupation until bacteriological 
examination has shown that he is not a carrier. The necessity 
for such precautions is apparent at once if we bear in mind 
that practically every one of the serious epidemics of septic 
sore-throat, so-called, which has occurred in many of our 
large cities during the past few years has been traced to a 
definite milk route and could be shown to be more or less 
intimately connected with an individual harboring the 
corresponding organisms in his throat. The difficulties 
which stand in the way of a successful preventive campaign 
against epidemics of this order are, however, so great that 
success could hardly be hoped for so long as raw milk is 
allowed to be sold. It accordingly follows that our simplest 
and most effective course would consist in securing the uni- 
versal enactment of a law prohibiting the sale of unpasteur- 
ized milk in all large communities. 

Septic sore-throat should be made a notifiable disease. 
Its victims should be bacteriologically controlled during 
their convalescence and carriers subjected to the same regu- 
lations as those which apply to the control of diphtheria and 
typhoid carriers. 

Extension of Carriers from Surgical Wards and Operating 
Rooms. — The connection between streptococcus carriers and 
puerperal fever is another problem that requires investiga- 
tion, as does the relation of carriers to those occasional 
streptococcus infections which occur even in our best surgical 






CAMP SEPTICEMIA AND BRONCHOPNEUMONIA 201 

services. In the olden days of the midwife, and when the 
rubber glove had not yet been introduced, puerperal fever 
was only too common, and then rightfully, no doubt, referred 
to manipulation with infected hands. But even nowadays 
puerperal fever has not entirely disappeared, even from our 
best obstetrical services, and there, are still deaths from this 
cause, the origin of which goes unexplained. Some of these 
cases may represent auto-infections, and occur in individuals 
who happen to be suffering from some respiratory ailment, 
apparently of a minor nature, at the time of their confine- 
ment. If this be so it would be indicated that cultures be 
taken from the throats of every such case and that suitable 
methods be put into operation to prevent auto-infection if 
the person should prove to harbor dangerous organisms. It 
would similarly suggest itself that passive carriers among 
the attendants be either eliminated or gowned, capped and 
masked when in the room or cubicle of the patient. That 
similar precautions in every surgical service would not be 
amiss, especially in winter time, when respiratory ailments 
with consequent coughing are so common, hardly requires 
mention. 

Prophylactic Vaccination. — In connection with the problem 
of camp septicemia, and in view of the apparently hopeless 
task of guarding against the dangers arising from strepto- 
coccus carriers by quarantine, prophylactic vaccination has 
been suggested as worthy of a trial. This seems thoroughly 
logical not only in view of the fact that in the animal experi- 
ment it is possible to produce a considerable degree of resist- 
ance against streptococci, but also since it has been shown 
in the human being that it is manifestly possible to secure 
resistance against the closely related pneumococcus. (See 
section on Pneumonia.) In this connection it is interesting 
to recall that among the 12,519 men who w T ere vaccinated by 
Cecil and Austin 17 against the three fixed strains of pneu- 
mococci (I, II and III) at Camp Upton in the latter part of 
the winter of 1918, 7 only subsequently developed strepto- 
coccus pneumonia (6 of the hemolyticus and 1 of the viridans 
type), while among the 19,481 un vaccina ted men there 
occurred 106 cases of streptococcus pneumonia (72 of the 



202 STREPTOCOCCUS INFECTIONS 

hemolyticus and 34 of the viridans type) during the same 
period of time (ten weeks) . Translated into percentages this 
means that of the vaccinated troops 0.055 per cent, only 
developed streptococcus pneumonia while the incidence 
among the non- vaccinated men was nearly ten times as great, 
viz., 0.54 per cent. It would appear, moreover, that the 
protection afforded by the pneumococcus vaccine against 
streptococcus pneumonia was fully three times as great for 
the viridans as for the hemolyticus. 

Especially convincing are the results which were noted 
among the 3500 colored troops, half of which were vaccinated 
while the remainder went un vaccinated. Among the former 
only 2 cases of streptococcus pneumonia developed during 
the period of subsequent observation, while 28 occurred 
among the un vaccinated men, although these men were living 
in the same part of the camp and closely associated oq drill 
grounds and in recreation and amusement halls. 

These results, of course, were most surprising, and while 
the incidence of pneumonia at the time was not nearly so 
great at Camp Upton as in some of the other camps, and 
while the absolute figures accordingly are not so striking, 
there can be no question regarding the facts. This being so, 
we can only say that if results like these can be obtained 
with a pneumococcus vaccine there should be no delay or 
hesitancy about the use of a corresponding streptococcus 
vaccine, which, indeed, might well be combined with the 
former and used not only in our military camps but also 
in our civil communities as a preventive against "winter 
infections " Although the latter are relatively unimportant, 
aside from the pneumococcus pneumonias, so far as fatalities 
go, they are very important nevertheless both from an 
economic standpoint and that of personal comfort. Evi- 
dently a great step has been made toward the conquest of 
this entire group of diseases, and it will be with the greatest 
interest that we shall look forward to the results that will be 
obtained in our camps during the coming winter. 



BIBLIOGRAPHY 203 



BIBLIOGRAPHY. 

1. Hamburger, W. W., and Mayers, L. H.: Pneumonia and Empyema 
at Camp Zachary Taylor, Ky., Jour. Am. Med. Assn., 1918, vol. lxx, p. 915. 

2. Fox, H., and Hamburger, W. W.: The Streptococcus Epidemic at 
Camp Zachary Taylor, Jour. Am. Med. Assn., 1918, vol. lxx, p. 1758. 

3. Levy, R. L., and Alexander, H. L.: The Predisporition of Strepto- 
coccus Carriers to the Complications of Measles: Results of Separation of 
Cariiers from Non-carriers at a Base Hospital, ibid., p. 1827. 

4. Cole, R., and McCallum, W. G.: Pneumonia at a Base Hospital 
Jour. Am. Med. Assn., 1918, vol. lxx, p. 1147. 

5. Cited by Cole, p. 1151. 

6. Duncan, L. C, and Sailer, J.: An Epidemic of Measles and Pneu- 
monia at Camp Wheeler, Ga., Mil. Surg., 1918, \ol. xlii, p. 123. 

7. Irons, E. E., and Marine, D.: Stieptococcal Infection Following 
Measles and Other Diseases, Jour. Am. Med. Assn., 1918, vol. lxx, p. 687. 

8. Gumming, J. G., Sproit, C. B., and Lynch, C: The Pneumonias, 
Streptococcus and Pneumococcus Groups, ibid., p. 1066. 

9. Smith, Th., and Brown, J. H.: A Study of Streptococci Isolated 
from Certain Presumably Milk-borne Epidemics of Tonsillitis, Jour. Med. 
Research, 1914, vol. xxvi, p. 455. 

10. Smillie: Studies of the Beta Hemolytic Streptococcus, Jour. Infect. 
Dis., 1917, vol. xx, p. 45. 

11. Schcttmuller : Munchen. med. Wchnscbr., 1903, vol. xxi, 

12. Dochez, A. R., and Gillespie, L. J. : A Biological Classification of 
Pneumococci by Means of Immunity Reactions, Jour. Am. Med. Assn., 
1913, vol. lxi, p. 727. 

13. Winslow, C. E. A.: An Outbieak of Tonsillitis or Septic Sore-throat 
in Massachusetts and its Relation to an Infected Milk Supply. 

14. Davis, D. J., cited by Capps, J. A.: Epidemic Streptococcus Throat, 
Jour. Am. Med. Assn., 1913, vol. lxi, p. 724. 

15. Stokes, W. R., and Hachtel, F. W.: Septic Sore-throat, a Milk- 
borne Outbieak in Baltimore, Public Health Reports, 1912, p. 44. 

16. Rosenow, E. C. : A Study of Streptococci from Milk and Epidemic 
Sore-throat, Jour. Infect. Dis., 1912, vol. xi, p. 339. 

17. Cecil, R. L., and Austin, J. H.: Prophylactic Inoculation Against 
Pneumococcus, Jour. Exp. Med., 1918, vol. xxviii, p. 19. 



INFLUENZA (PFEIFFER TYPE). 

The bacillus which was first described by Pfeiffer in 1892 1 
is now accepted as the causative agent of a certain type of 
pandemic influenza. All investigators who have been able 
to study this question at a time when grippe of that type has 
been prevalent have been able to confirm Pfeiffer's obser- 
vations and have come to the same conclusion. 2 

Any doubt that may have existed in the past was largely 
due to the fact that, clinically, we are not able to distinguish 
between grippe due to the influenza bacillus and grippe due 
to such organisms as pneumococci, streptococci, various 
diplococci resembling the meningococcus, etc. It would 
evidently not be justifiable to conclude that Pfeiffer's bacillus 
is not the cause of a form of pandemic influenza, on the 
ground that this organism is not found in clinical grippe at a 
time when the pandemic form of the malady is on the decline 
or has already disappeared. Tedesco, 3 Ruhemann 4 and nota- 
bly Scheller 5 have shown that whereas maximal percentage 
findings of Pfeiffer's bacillus will be obtained at a time when 
this form of pandemic grippe is in full sway, the figures 
will progressively decline during subsequent secondary out- 
breaks and in proportion to the extent to which ordinary 
grippe again comes to the foreground, so that after a number 
of years the influenza bacillus will be met with only excep- 
tionally while pneumococci and streptococci especially again 
control the situation. This is well illustrated by Scheller' s 
figures: During the winter of 1906-1907, when influenza 
of the pandemic type occurred in Germany, Scheller found 
influenza bacilli in 90 per cent, of the sputa which had been 
sent in with the diagnosis of influenza. During the winter of 
1907-08 this figure dropped to 20 per cent., and during the 
following summer and the winter of 1908-1909 not a single 
sputum that was sent in from grippe cases contained the 
organism in question but pneumococci instead. 



INFLUENZA 205 

Another objection which was raised to Pfeiffer's claim that 
his organism was the cause of influenza in 1889 to 1892 was 
the observation that the organism in question could be found 
not only in individuals who were suffering from the malady 
at the time, but also in persons afflicted with other diseases, 
notably phthisis, measles, scarlatina and diphtheria, as well 
as in people who were to all appearances perfectly well and 
who had not passed through an attack of influenza. That the 
true meaning of such findings was not appreciated at the time 
can scarcely be surprising, while in view of subsequent and 
similar observations in connection with cholera, typhoid 
fever, diphtheria, etc., it is of course perfectly clear to us that 
they do not represent an argument against the pathogenic 
character of the disease but merely indicate that in influenza 
also carriers are of common occurrence. The frequent presence 
of the organisms in the sputa of patients suffering from other 
diseases at the time merely indicates that such maladies 
create a particularly favorable soil for the development of the 
influenza bacillus. We have seen before how readily measles 
cases fall prey to hemolytic streptococci, and in influenza we 
probably have analogous conditions. 

Unfortunately we are as yet in comparative ignorance 
regarding many of the phases of the carrier problem in con- 
nection with influenza, but enough has been learned to war- 
rant the conclusion that in the dissemination of this malady 
also, carriers both of the active and the passive type play a very 
important role. 

Scheller thus noted that during the epidemic of 1906-07, 
of 109 supposedly healthy individuals, 25 (i. e., about 24 
per cent.) harbored the influenza bacillus in the nasopharynx. 
Of the total number 20 had passed through an attack of the 
malady, and of these in turn 15, i. e., 75 per cent., gave a 
positive result; 89 gave no history of a past attack, and of 
these in turn 10, i. e., 11 per cent., were carriers. These 
figures are, of course, based on too small a series of exami- 
nations as to warrant any far-going conclusions regarding the 
quantitative role which carriers, as compared with patients, 
play in the dissemination of the disease. 



206 INFLUENZA 

Duration of Carrier State. — Scheller unfortunately does not 
mention how long after the attack the individuals were 
examined nor how long the carrier state lasted, and so far as 
I have been able to ascertain no other studies in this direction 
have as yet been made. That the organisms may persist in 
tuberculous individuals for a particularly long while is sug- 
gested not only by Scheller's observation, that at a time 
when influenza bacilli were no longer found in the sputa of 
cases that had been diagnosed as grippe, 3 per cent, of the 
tuberculous sputa still contained the organisms in question, 
but also by actual observation in concrete cases, where they 
could be demonstrated years after the attack. 

Practically important, from the standpoint of the dis- 
semination of the malady, is the fact that influenza may 
assume a chronic course, and that in such individuals also the 
organisms may persist for months and even years. (Pfeiffer, 
Leichtenstern 6 ) . 

In fine, we must bear in mind that, as in other respiratory 
infections, some cases run so mild a course as hardly to 
attract the patient's attention to his own condition, and it 
goes without saying that such individuals also play an impor- 
tant role in bringing about the spread of the disease. 

Origin of Secondary Outbreaks. — The discovery that some 
individuals may harbor the influenza bacillus for a long time 
enables us to understand how secondary outbreaks may occur 
through a period of years when once the disease has appeared 
in a given locality. The cause for wonder is not so much 
that such secondary outbreaks do occur, but rather that the 
malady dies out after a certain length of time. This is usually 
explained by assuming that suitable soil is no longer available ; 
that an entire community has become immune, in so far as 
a natural immunity did not exist already before in some. Of 
the production of such an immunity, however, we have no 
laboratory evidence, and we may assume as well that through 
animal passage of a kind the organism has gradually lost its 
virulence, just as we assume that through animal passage of 
a kind it may increase or regain its virulence. 

Habitat of the Organism. — As regards the habitat of the 
organism in healthy carriers, Scheller found that positive 



CULTURE MEDIUM 207 

cultures are most apt to result if the secretion is obtained 
from the pharyngeal tonsil. This should be borne in mind, if 
a bacteriological diagnosis is desired, in clinically doubtful 
cases. 

Mode of Infection. — From the studies of Pfeiffer we know 
that the viability of the influenza bacillus outside of the 
human body is relatively slight when perfectly dry, but that 
in the presence of moisture the organisms retain their power 
of infecting for at least a fortnight. Pfeiffer concludes from 
his experiments that the dissemination of the disease through 
dried sputum by currents of air probably only occurs to a 
limited degree, and that infection usually takes place through 
a direct transference of the fresh and moist secretions of the 
nasal or bronchial mucosa. In other words, we have reason 
for believing that the dissemination of the disease takes place 
essentially through sputum spray from patients or carriers. 

Concrete examples illustrating the activity of carriers in the 
dissemination of the disease are not as yet available, and it is 
scarcely likely that major epidemics will lend themselves to 
studies of this sort. 

The Recognition of Influenza Carriers. — As the influenza 
bacillus readily dies when kept in the dry state, for even a 
very short time, it is essential to have the necessary culture 
media right at hand when individuals are to be examined in 
order to ascertain whether they are carriers. 

The necessary secretion is best obtained by the aid of the 
West tube, remembering that the pharyngeal tonsil seems to 
be the favorate habitat of the organism in question. If such 
a tube is not available one will have to give the wire of an 
ordinary swab the necessary curve, so as to enable one to 
pass behind the veil of the palate. The mop itself should, of 
course, be sterile, and care be taken to avoid contact with the 
secretions of the mouth itself. 

Culture Medium. — For purposes of culture, blood-agar is 
necessary. While pigeon blood gives particularly good results, 
human blood or the blood of the usual laboratory animals is 
perfectly satisfactory. As it is the hemoglobin which the 
influenza bacillus requires, and as this is needed only in very 
small amounts, it is not necessary to prepare the blood-agar 



208 INFLUENZA 

in the usual manner by adding a larger volume of blood to a 
tube of liquefied agar and then plating or slanting the mix- 
ture. Perfectly satisfactory results will be obtained if a few 
loopfuls of a fairly rich corpuscle emulsion are smeared over 
the surface of an ordinary agar slant a short while before 
preparing the culture ; the amount may be so small that no 
color is imparted to the agar. Sub-cultures are prepared in 
the same manner and had best be renewed every four or five 
days though the organism will usually be found in a viable 
condition even after a fortnight. The use of plates for initial 
cultures is, of course, advantageous, but not a necessity. 

After smearing the surface of either plates or slants the 
cultures are kept at 37° to 40° C. for from eighteen to 
twenty-four hours, when they are examined. 

The influenza bacillus grows in the form of minute, trans- 
parent, drop-like colonies which manifest no tendency to 
coalesce, but remain perfectly discrete and are usually quite 
numerous. 

Such cultures form a marked contrast to control cultures 
on plain agar on which no growth of the influenza bacillus 
at all takes place, and only isolated colonies of organisms, 
such as streptococci, pneumococci and the like appear. 

In the beginning, before the observer has gained the neces- 
sary experience, it is advisable always to prepare such control 
cultures for comparison with those obtained on theblood-agar. 

In the New York Board of Health laboratories the follow- 
ing medium has been employed during the recent epidemic 
of influenza: Plates are charged, each with 12 c.c. of neutral 
5 per cent, glycerin-veal infusion agar, to which 0.5 c.c. of 
sterile citrated horse blood is then added at a temperature 
of from 90° to 100° C. The blood and medium are carefully 
mixed, so as to produce no bubbles, when the plates are 
allowed to cool and tested for twenty-four hours for sterility. 
The blood used is citrated by mixing 1 part of a 10 per cent, 
solution of sodium citrate in saline with 10 parts of blood 
under sterile precautions. On this medium the influenza 
bacillus grows readily and quite profusely. 

Microscopic Appearance of the Influenza Bacillus. — For 
microscopic examination it is well to stain one smear accord- 



MANAGEMENT OF THE INFLUENZA CARRIER 209 

ing to Gram — counterstaining with saffranin — to which the 
organism is negative, and another with dilute carbol-fuchsin, 
Frankel's carbol-gentian- violet or Sterling's gentian violet — 
exposure for about five minutes. 

Aside from its negative behavior to Gram the pleomor- 
phism of the influenza bacillus is particularly characteristic. 
While the organism is usually described as a bacillus, measur- 
ing about 0.5 ju in length by 0.2 or 0.3 \x in breadth, the be- 
ginner is very apt to mistake it for a coccus, and more 
particularly for a diplococcus, as it shows a marked tendency 
to grow in pairs, arranged end to end. 

Involution forms are also seen quite frequently, among 
which giant forms with club-shaped ends — usually single — 
are common. Various writers further have described the 
occurrence of so-called pseudothreads in cultures of the 
organism. Such formations Pfeiffer was originally inclined 
to regard as pseudo-influenza bacilli, but he convinced him- 
self that thread formation could unquestionably occur in pure 
cultures of the influenza bacillus proper. They are now 
viewed as involution forms. 

In stained specimens it will be noted that many of the 
organisms stain more deeply at the ends than in the middle ; 
this is shown particularly well in the Gram specimens after 
counterstaining with safranin. 

The identification of the influenza bacillus by serological 
methods is not practical, owing to the difficulties attending 
the immunization of animals. Very few investigators have 
been able to obtain agglutinating sera with a titer of 300 or 
more, and then only at the expense of a very large number of 
animals. 

For the present, then, the recognition of the influenza 
bacillus will have to be based upon its absolute hemoglobino- 
philia, its pleomorphism, the tendency to polar staining and 
its negative behavior to Gram. 

Management of the Influenza Carrier. — The same remarks 
apply here that have been made in connection with the 
consideration of streptococcus carriers. Our prime consider- 
ation should, of course, be to attempt to prevent the produc- 
tion of carriers rather than the quarantine of the latter, To 
14 



210 INFLUENZA 

this end every effort should be made to prevent the disease 
from gaining headway when once it has appeared. This may 
be attempted, on the one hand, through a most widespread 
and continuous instruction not only of the public, but of the 
general practitioner as well, who himself is but rarely suffi- 
ciently trained in sanitary work to undertake such a problem 
on his own initiative and, on the other, in the isolation of 
every case of recognized influenza. In connection with our 
present epidemic the public and the medical profession, both 
in civil and military life, were found completely unprepared, 
and, as a consequence, no steps that were taken when the 
disease had once obtained a proper start were found to avail. 
To the thoughtful observer it has been a shock to find influ- 
enza patients placed promiscuously in the general wards of 
our hospitals, and that no attempt at masking had been made 
for a long time which latter, of all prophylactic measures in 
connection with the dissemination of respiratory infections 
is, after all, the one single method that is of unquestionable 
value. 

Whether or not vaccination against influenza will prove 
successful time only can tell, but on theoretical grounds it 
would certainly appear to be indicated. In any event it 
would appear wise to vaccinate against the complicating 
pneumococcus and streptococcus pneumonia, using a vac- 
cine such as that which has been described under the corre- 
sponding headings. 

BIBLIOGRAPHY. 

1. Pfeiffer, P.: Die Aetiologie d. Influenza, Ztschr. f. Hyg., 1893, vol. 
xiii, p. 357. 

2. Weichselbaum : Beit. z. Aetiologie d. Influenza, Wien. klin. Wchnschr., 

1892, Nos. 32 and 33. 
Baumler: Die Influenzaepidemie 1893-94 in Freiburg, Munchen. med. 

Wchnschr., 1894, No. 9. 
Huber: Ueber den Influenzabazillus. Ztscbr. f. Hyg., 1893, vol. xv. 
Borchaidt: Beobachtungen iiber d. Vorkommen d. Pfeifferschen 

Bazillen, Berl. klin. Wchnschr., 1894, No. 2. 
Kruse: Zur Aetiologie u. Diagnose d. Influenza, Deutsch. med. 

Wchnschr., 1894, No. 24. 

3. Tedesco, F. : Bericbt iiber d. Influenzauntersuchungen, etc., in d. 
letzter 10 Jahren (1896-1906), Centralbl. f. Bakt. Abth. I, 1907, vol. xliii. 

4. Ruhemann: Zur epidemiologischen Bedeutuog d. Influenzabazillen. 
Berl. klin. Wchnschr., 1907, p. 1173. 



BIBLIOGRAPHY 211 

5. Scheller, R. : Ueber d. Verbreitung d. Ii)fluenzabazillen; eine epidemio- 
logische Studie, Centrlbl. f. Bakt. AVth. I, 1909, vol. 1, idem, Die Gruppe d. 
hemoglobinophilen Bakterien, Handbuch d. pathogenen Microorganismen 
von Kolle u. Wassermann, vol. v, 2d ed., p. 1257. 

6. Leichtenstern: Influenza und Dengue, Nothnagel's spez. Path. u. 
Ther., 1896, vol. iv, 2d ed., 1912. 

7. Cantani: Immunisierungsversuche gegen Influenza, Ztschr. f. Hyg., 

1903, vol. xlii, p. 505 
Odaira: Beit. z. Kenntniss d. hemoglobinophilen Bazillen, Centralb. f. 
Bakt., Abtb. I, 1911, vol. hfi. 



APPENDIX. 

The unfortunate lack of recognition on the part of the 
State and municipal health authorities of our country of the 
importance of carriers in the dissemination of infectious 
diseases is best illustrated by the complete absence of any 
specific laws or regulations appertaining to their manage- 
ment, up to the year 1915, and by the small number of 
States and municipalities which have enacted such laws since 
that time. This is a serious reflection both upon the intelli- 
gence and the statesmanship of our law-making bodies as 
well as upon the efficiency of those medical officers who have 
been entrusted with the duty of safeguarding the public 
health . 

The few regulations which have actually be enacted up to 
January 1, 1918, are given below and have been arranged 
in two series, the first comprising the State laws and regula- 
tions relating to carriers, and the second the corresponding 
municipal ordinances and rules as based upon the public 
health records issued by the United States Public Health 
Service. An analysis of these laws will show at once that 
some steps have been taken in the right direction, but that 
for the most part the laws do not go far enough, that in 
themselves, without supporting legislature, they will not 
lead to the desired end for the reason that provision has only 
exceptionally been made for an elevation of the corresponding 
boards of health to that state of political and financial 
independence in the absence of which modern sanitary work 
cannot be properly carried on. 

STATE LAWS AND REGULATIONS PERTAINING TO 
INFECTION CARRIERS. 

Arizona. 
No specific regulations. 



STATE LAWS AND INFECTION CARRIERS 213 

California. 

(Reg. Board of Health, August 1, 1914, and September 

4, 1915.) 

Rule 8. — Diphtheria. — When isolation and quarantine for 
diphtheria have been established in accordance with Rules 
6 and 7, any person living within the quarantined premises, 
but staying at all times outside the area of isolation, may be 
given permission by the local health authority to go to and 
from the premises if the following conditions have been met: 
Cultures taken from his nose and throat and submitted to a 
State or municipal laboratory must have been reported as 
negative for diphtheria. All other members of his household 
must, if possible, have had cultures taken from their noses 
and throats, and those persons whose cultures were found 
positive must be isolated so that there is no contact with 
him. He must also agree to avoid any occupation or practice 
which would make him especially dangerous in the event of 
his becoming a carrier. The local health authority may 
revoke this permission if the above provisions are not com- 
plied with. 

In his investigation of a case of diphtheria the local health 
authority shall make inquiry regarding those who have come 
in contact with the patient, and if any of them contemplate 
leaving the jurisdiction of the local health authority within 
two weeks after the last exposure the local health authority 
shall notify the State Board of Health of their names and 
destinations. 

Note 1. — Rule 8 permits the wage-earner to continue his 
occupation unless he has already become a carrier or unless 
his occupation is such that he would probably infect others 
if he became a carrier. Such occupations are such as the pro- 
duction or handling of milk and any work which iuvolves 
contact with large numbers of persons, especially young 
children. 

Note 4. — The purpose of the establishment of an area of 
enforced isolation within the quarantined premises is not 
only to prevent acute cases among the contacts, but especially 
to diminish the formation of carriers. Under the previous 



214 APPENDIX 

system of enforced quarantine with optional isolation the 
formation of carriers frequently occurred. Carriers are much 
more dangerous to the community, in the aggregate, than 
the acute cases. 

Note 5. — Although diphtheria antitoxin is efficient in 
preventing contacts from contracting diphtheria, it will not 
prevent their becoming carriers. Therefore no relaxations of 
the precautions against contact with infectious persons can 
be permitted to those who have been immunized. Persons 
immune owing to previous attacks of the disease also may 
become carriers and must observe the precautions. 

Rule 9. — Release from Quarantine. — As soon as a diph- 
theria patient is free from all symptoms, the attending 
physician shall notify the local health authority of the fact. 
The local health authority or his representative shall there- 
upon make an investigation, and, if he finds that the case 
has made a complete clinical recovery, as reported, he shall 
take cultures from the nose and throat of the convalescent 
at intervals of not more than a week and not less than forty- 
eight hours, and shall submit them to a State or municipal 
laboratory. Where it is impractical for a local health 
authority or his deputy to take the cultures he may permit 
the attending physician to represent him for that purpose. 
As soon as two successive negative cultures from both nose 
and throat have been obtained the local health authority 
shall terminate the quarantine and the isolation. If two 
successive negative cultures cannot be obtained from the 
convalescent within one month after recovery he is to be 
regarded as a carrier and the quarantine is to be terminated, 
leaving the isolation in force until removed according to 
Rule 10. If the area of isolation and the quarantined prem- 
ises coincide the warning card for isolation is to be substi- 
tuted for the placard for quarantine. 

Rule 10. — Release from Isolation. — At the end of four 
weeks after complete recovery from diphtheria, as deter- 
mined by the local health authority in accordance with the 
provisions of Rule 9, if positive cultures are still obtained, 
the local health authority shall at once report to the State 
Board of Health the circumstances of the case and shall 



STATE LAWS AND INFECTION CARRIERS 215 

recommend either a continuation of isolation or release from 
isolation under certain specified restrictions. Isolation is 
not to be continued for more than six weeks after complete 
recovery, except when specified by the State Board of Health. 
When isolation is terminated the objects in the area of isola- 
tion must be disinfected. 

Rule 11. — Diphtheria Carriers. — Any person who has been 
free from symptoms of diphtheria for a month or longer and 
who harbors diphtheria bacilli is a carrier. Any known or 
suspected diphtheria carrier shall be reported to the local 
health authority, who shall investigate and report to the 
State Board of Health. Pending the receipt of instructions 
from the State Board of Health the local health authority 
shall isolate or quarantine the carrier if in his judgment the 
danger to the community necessitates such action. In the 
event of any known or suspected carrier leaving the juris- 
diction of a local health authority the State Board of Health 
shall be notified by the local health authority of the name of 
the carrier and his destination. 

Rule 12. — Epidemiological Investigation. — Whenever a 
local health authority receives reports of the existence of 
diphtheria within his jurisdiction or is notified by the State 
Board of Health that cases of diphtheria reported from other 
communities have probably received the infection within his 
jurisdiction, he shall conduct an investigation to ascertain 
the sources of infection and shall report the results to the 
State Board of Health. He shall immediately take such 
action for the protection of the community as may be indi- 
cated by the conditions discovered or suspected in the course 
of his investigation. 

Note 1. — Diphtheria in Schools and Institutions. — If diph- 
theria appears in a school or public institution, and there 
is reason to suspect that the disease was contracted within 
the institution, cultures from the noses and throats of all the 
officers, teachers, pupils and inmates of the institution shall 
be taken, in order that the epidemic may be promptly 
checked by isolation or exclusion of the carriers. 

When diphtheria is present in a community, teachers must 
send home any children who come to school showing symp- 



216 APPENDIX 

toms suggestive of infectious disease and must report at once 
to the local health authority, so that he can make an investi- 
gation and determine whether it is safe for the child to return 
to school. During an outbreak of diphtheria teachers shall 
also report to the health authority the return to school of 
any pupil after an unknown illness, so that it may be deter- 
mined whether he is a diphtheria carrier. 

Colorado. 
No specific regulations. 

District of Columbia. 

There are no regulations covering infection carriers as 
such. Carriers of infection are regarded as active clinical 
cases from the point of view of regulating the control of a 
given disease.* 

Connecticut. 

(Sanitary Code, Chapter I, Communicable Diseases, 1918.) 

Definition of the Term "Carrier." — A carrier is one who 
harbors in his body the microorganisms of a communicable 
disease, but who at the time is apparently in good health. 
A carrier may convey the infectious agent to another person 
and, under favorable conditions, the germs may incite the 
disease in his own body. 

Regulation 22. — Presumably Exposed Persons May be 
Examined and Controlled. — When a health officer has reason- 
able grounds to believe that a person or persons may have 
been exposed to a communicable disease, he may control them 
as known contacts, making such examinations and adopting 
such measures as he deems necessary and proper for the pro- 
tection of public health and the prevention of the spreading 
of disease. 

Regulation 23. — Methods of Isolation of Carriers. — 
Carriers of the infectious agent of asiatic cholera, dysentery, 
bacillary, paratyphoid, typhoid fever, shall be controlled 

* As per Letter from the Chief of the Bureau of Preventable Diseases. 



STATE LAWS AND INFECTION CARRIERS 217 

by isolation or restriction of movement until repeated exami- 
nations of excreta show the absence of the infectious agent. 

Note 2. — It is desirable when possible to release cases of 
dysentery, amebic, dysentery, bacillary, typhoid fever only 
after the disappearance of the infective organisms has been 
shown by laboratory examinations of the excreta. 

Regulation 24. — Removal to Hospital of Certain Cases. — 
When in the opinion of the health officer or the State Com- 
missioner of Health proper isolation or quarantine of an 
affected person or persons, carrier or contact is not, or cannot 
be, effectively maintained on the premises occupied by such 
person or persons by methods designated in this chapter, he 
may remove or require the removal of such person or persons 
to a hospital or other proper place designated by him; or he 
may employ such guards or officers as may be necessary to 
maintain effective isolation or quarantine. 

Regulation 32. — Observance of Quarantine and Instruc- 
tions . — Every person who is affected with a communicable 
disease, who is a carrier of the germs of a communicable dis- 
ease, or who is suspected of having come in contact, directly 
or indirectly, with a case of communicable disease, shall 
strictly observe and comply with all orders, quarantine regula- 
tions and restrictions given or imposed by the local health 
authority or the State Commissioner of Health in conformity 
with law. 

Carriers of the infectious agent of diphtheria shall be iso- 
lated until two successive cultures from both the nose and 
throat, taken at least twenty-four hours apart, show the 
absence of the Klebs-Loffier bacillus. 

Note 1. — In cases in which the organism persists for an 
unduly long time after convalescence, cultures should be sub- 
mitted for a virulence test to a laboratory approved by the 
State Department of Health or the advice of the State 
Department should be sought. 

Carriers of the infectious agent of cerebrospinal meningitis 
shall be isolated until examination of the nasal and throat 
discharges show the absence of the specific diplococcus. 



218 APPENDIX 

Idaho. 
(Reg. State Board of Health, May 13, 1914.) Quarantine. 

Rule 18. — Diphtheria. — For the patient: Isolation for 
fourteen days after recovery of cases of diphtheria may be 
released from quarantine when two cultures from the throat 
examined by the State Board of Health laboratory three 
days apart show the patient to be free of the disease. 

For exposed persons: Quarantine for fourteen days from 
last exposure or until two successive cultures from the throat 
made three days apart show the absence of diphtheria bacilli. 

Illinois. 
(Reg. Board of Health, February 16, 1915.) 

Rule 1. — Every physician, attendant, parent, house- 
holder or other person having knowledge of a known or sus- 
pected case of typhoid fever, or of a person known or sus- 
pected to be a "typhoid carrier," must immediately report 
the same to the local health authorities. 

Rule 12.— Any person known to be or suspected of being 
a typhoid " carrier ," and therefore capable of spreading 
typhoid infection, shall be treated as a typhoid patient even 
though to all outward appearances such person may appear 
to be well, and shall be subject to the rules governing typhoid 
fever cases : Provided, however, That in order to meet con- 
ditions peculiar to individual cases the State Board of Health, 
upon its own initiative or upon recommendation of the local 
health authorities, may modify or relax these rules. 

Rule 7. — A person recovered from typhoid fever will not 
be permitted to engage in any manner in the handling or 
preparation of foodstuffs, milk or milk products, including 
the handling of milk containers, until one month after date of 
recovery, and until after the intestinal discharges have 
ceased to be more copious, liquid or frequent than normal, 
or until such time as it has been ascertained that such person 
is in no danger of spreading the infection. 

Typhoid Fever. — Rule 5 (c). — Convalescents. — No person 
recovered from typhoid fever shall be permitted to engage 



STATE LAWS AND INFECTION CARRIERS 219 

in any manner in the handling or preparation of foodstuffs, 
milk products, including the handling of milk containers, 
until the stool and urine of such persons are found by labora- 
tory examination to be negative to typhoid bacilli. 

Note. — Examinations of stool and urine for typhoid bacilli 
will be made free of charge at the laboratory of the State 
Department of Public Health, Springfield. Containers for 
forwarding specimens will be furnished on request addressed 
to the laboratory of the Department at Springfield. 

Penalty for Violation. — A fine of not more than $200 for 
each offence or imprisonment in the county jail not exceeding 
six months, or both. 

Epidemic Meningitis. — Rule 3. — Quarantine. — Occupants 
of the premises on which the case exists or others who have 
been exposed to the case should be confined until cultures 
have been made and it has been determined by laboratory 
examination that they are not "carriers" of the disease. 

Occupants of the premises proved not to be carriers and who 
desire to leave the quarantined premises may be removed 
after disinfection of persons and clothing, but they must not 
return to the quarantined premises during the period of 
quarantine. 

If any such removed occupants are school children or school 
teachers they should again be cultured after removal and 
should not be permitted to return to school until proved by 
laboratory examination not to be carriers of the disease. 

Quarantine of the infected premises should not be raised 
until the patient or patients have recovered and until two 
successive negative cultures at three-day intervals have 
been obtained from the patient and also one negative culture 
from attendant and all other inmates of the premises and 
contents have been thoroughly disinfected in manner 
approved by the State Department of Public Health. (Quar- 
antine in epidemic meningitis cannot be terminated with 
safety without resort to laboratory examination of cultures.) 

Indiana. 
No specific regulations. 



220 APPENDIX 

Iowa. 
(Reg. Board of Health, September 28, 1916.) 

Rule 2. — Section 1. — Diphtheria, Period of Quarantine. — 
The period of quarantine for diphtheria shall be determined 
by release cultures and the following rules shall be rigidly 
observed : 

Rule 1 . — Cultures for Release. — Cultures for release shall 
be taken by the attending physician from both nose and 
throat of the patient, such cultures to be taken not less than 
two hours following the application of an antiseptic solution 
to the nose or throat when such treatment has been given. 

Rule 2. — First Culture Taken. — No cultures for release 
shall be taken until five days after the disappearance of all 
membrane or inflammation of the nose or throat. 

Rule 3. — Second Culture Taken. — Second and subsequent 
cultures shall not be taken within twenty-four hours of the 
preceding culture. 

Rule 4. — Cultures for Release Examined by Bacteriologist. 
— All examinations of cultures for release shall be made by a 
bacteriologist appointed by the director of the State Bacterio- 
logical Laboratory. 

Rule 5. — Two Negative Culture Reports Necessary. — 
Quarantine shall not be released until two consecutive nega- 
tive reports on cultures have been reported to the attending 
physician by the bacteriologist. 

Diphtheria Carrier after Twenty-eight Days in Quarantine. 
—In case a person has been in quarantine for twenty-eight 
days after the beginning of the disease, and still harbors 
diphtheria bacilli in the nose or throat, as shown by a positive 
report from the bacteriological laboratory, and in case such 
person has entirely recovered from the disease, such person 
shall be regarded as a "diphtheria carrier" and treated as 
described iu Section 4 of this rule. 

Rule 6. — Section 4. — Diphtheria Carriers. — Every person 
who is a "diphtheria carrier, ' that is, harbors diphtheria 
bacilli in the nose or throat, as shown by a positive report 
from the bacteriological laboratory, shall be confined to 
certain premises which shall be placarded "Diphtheria car- 



STATE LAWS AND INFECTION CARRIERS $21 

rier here," until such time as the diphtheria bacilli are no 
longer present or have been found not to be capable of pro- 
ducing the disease, as shown by a report from the bacterio- 
logical laboratory. Persons on the premises who are not 
diphtheria carriers need not be confined to the premises, 
but may be permitted to go back and forth from the premises 
to other places, provided cultures have been taken from the 
nose and throat and seat to the bacteriological laboratory 
within a day after the premises are placarded and reported 
to be negative. 

Persons on Premises of Carriers.- — Persons on the premises 
from whom no cultures are taken shall be confined to the 
premises as if they were carriers. 

Carriers When Released. — Carriers shall not be released 
until two consecutive negative reports have been received 
from the bacteriological laboratory on cultures taken from 
both nose and throat. 

Section 5. — Healthy Persons; How Released from Diph- 
theria Quarantine. — Healthy persons living on premises where 
there is a case of diphtheria may be permitted to leave the 
premises, provided it has been shown by a report from the 
bacteriological laboratory on a culture taken from the nose 
and throat that such persons are not carriers of diphtheria 
bacilli. 

Kansas. 

(Reg. Board of Health, March 20, 1916.) 

Rule 10.— Any person who is known to harbor the bacilli, 
virus or infective agent of any communicable disease, even 
though manifesting no symptoms of such disease, is hereby 
declared to be a carrier and a menace to the public health, 
and the name and address of such person shall be reported 
immediately to the local city or county health officer in whose 
jurisdiction such person resides. The local health officer 
shall immediately investigate and report to the State Board 
of Health. Pending the receipt of instructions from the 
State Board of Health the local health officer shall isolate 
or quarantine the carrier, if in his judgment the danger to 
the community necessitates such action. In the event of 



222 APPENDIX 

any known or suspected carrier leaving the jurisdiction of the 
local health authority the State Board of Health shall be 
notified by the local health officer of the name of the carrier 
and his destination. 

Louisiana. 

There are no specific legislative enactments relating to 
infection carriers. The Sanitary Code merely requires that 
"no cook, assistant cook, waiter or other worker in the 
kitchen or dining room must be employed by any hotel, 
restaurant, boarding house or other public eating house 
. . . who is recently convalescent from pneumonia, 
diphtheria or typhoid fever."* 

Maine. 

There are no specific legislative enactments relating to 
infection carriers. Reliance is placed on Rale 7 of the Rules 
and Regulations of the State Department of Health relating 
to infectious diseases and to Sections 22, 24 and 65 of the 
Health Laws of the State, which read as follows: 

Rules and Regulations Relating to infectious Diseases, 1916. 

Rule 7. 

Contacts and Suspects. — Persons who have been exposed 
to an infectious or contagious disease, or who are suspected 
of having an infectious or contagious disease, or of being 
infectious or the carriers of infection, may be placed under 
quarantine or observation as is provided in Rule 6, until the 
period of incubation has elapsed, or until the nature of the 
disease has been determined, or the period of infectiousness 
and danger to the public has ended; and said persons shall 
obey all orders and shall be guided by the instructions which 
may be given by the local board of health. 

Abstracts of Public Health Laws, Chapter 197, Laws of 1917. 

Section 22. — Regulations Against Infectious Diseases. — 
And the said Board of Health may from time to time, make, 

* As per letter from the President of the State Board of Health, 



STATE LAWS AND INFECTION CARRIERS 223 

alter, modify or revoke rules and regulations for guarding 
against the introduction of any infectious or contagious 
diseases into the State. And the said Board of Health may 
declare any and all of its rules and its regulations made in 
accordance with the provisions of this section to be in force 
within the whole State, or within any specified part thereof, 
and to apply to any person or persons, family, camp, building, 
vessel, railroad car or public vehicle of any kind. 

Section 24. — Penalty for Refusing to Obey Regulations. — 
Any person who shall neglect or refuse to obey the said rules 
and regulations or who shall wilfully obstruct or hinder the 
execution thereof, shall be punished by a fine of not more 
than $500, or by imprisonment in the county jail for a period 
of not more than six months or by> both fine and imprison- 
ment. 

Section 65. — Infected Houses Shall Not Be Let. — No person 
shall let or hire any house or room in a house in which any 
of the diseases have existed for which disinfection may be 
required by the State Board of Health without having caused 
the house and the premises used in connection therewith to 
be disinfected to the satisfaction of the local board of health. 



Maryland. 

" Carriers of communicable diseases are controlled by the 
powers that are given the State Department of Health to do 
whatever is necessary to prevent disease being communi- 
cated to the well citizens of the State. Therefore in cases 
of milk outbreaks of typhoid fever examination is made for 
typhoid carriers and if such persons are found they are ex- 
cluded from the dairy and confined as much as is deemed 
necessary to the health officers to protect other people. 

"The same is true of carriers of diphtheria organisms until 
the examinations are found by animal experiment to be non- 
virulent."* 

* As per letter from the Chief of the Bureau of Communicable Diseases, 



224 APPENDIX 

Massachusetts. 

No Specific State Regulations Regarding Infection Car- 
riers. — Local boards of health have a right to make and 
enforce their own regulations without reference to State 
authority.* 

Michigan. 

Infection carriers are treated in this State in the same 
manner as communicable diseases and their control placed 
under the supervision of the health officer of the community, f 

Minnesota. 
(Reg. Board of Health, November 19, 1913.) 

704. — In all cases diagnosed diphtheria, laryngeal croup 
or membranous croup upon clinical findings or diphtheria 
upon laboratory findings, two successive negatives on sepa- 
rate nose and throat cultures are required before release of 
quarantine in cities and villages and in country districts 
within two miles of a city or village. Cultures should be sent 
at least once a week after the patient recovers, but no case 
may be held in quarantine more than six weeks after all 
clinical symptoms have disappeared. 

705. — All members of a household in which diphtheria 
exists shall be quarantined unless the patient is entirely 
isolated in a portion of the house used for no other purposes 
and is in charge of a reliable attendant. 

If proper isolation obtains and the laboratory diagnosis 
on nose and throat cultures from members of the household 
employed at gainful occupations is "No diphtheria bacilli 
found," such persons may be released from quarantine, pro- 
vided they make a declaration in writing to the health officer 
that they will not come in contact with the patient, the 
patient's room or any thing or any person coming in contact 
with the patient or the patient's room. The health officer 

* As per letter from the Director of the Division of Communicable 
Diseases. 

t As per letter from the Assistant Secretary. 



STATE LAWS AND INFECTION CARRIERS 225 

shall issue written permits of release, which may be revoked 
if the above provisions are not complied with. 

706. — In all cases diagnosed diphtheria, laryngeal croup 
or membranous croup upon clinical findings or diphtheria 
upon laboratory findings, quarantine may be released in 
country districts more than two miles from a city or village 
three weeks after all clinical symptoms have disappeared, or 
earlier if two successive negatives on separate nose and 
throat cultures have been reported in accordance with 
regulation 710. 

707. — Patients released from quarantine upon the expira- 
tion of the prescribed quarantine period, whether in cities, 
villages or country districts, shall not be permitted to attend 
any public, private, parochial, church or Sunday school, or 
any public or private gathering, until two successive negatives 
have been reported in accordance with regulation 710. In 
such cases the patients may go to their physician or health 
officer to have cultures taken. 

708. — Persons associated with a case and wishing to leave 
the premises before quarantine is raised shall be separated 
from the patient and shall have nose and throat cultures taken 
by the health officer or attending physician. If the labora- 
tory diagnosis is "No diphtheria found," the clothing to be 
worn or taken away from the house shall be disinfected and 
the person shall take a full bath before being released. 

After fatal cases the members of the household shall not 
be released from quarantine until the above measures have 
been carried out. 

709. — The control of diphtheria in public institutions shall 
be governed entirely by laboratory examinations. Imme- 
diately after the appearance of diphtheria in an institution 
the head of the institution shall notify the State Board 
of Health of the fact. Each person whose cultures show 
diphtheria bacilli shall be quarantined, whether symptoms 
exist or not, until one negative report on separate nose and 
throat cultures has been made, after which the person shall 
be properly cleansed, the clothing properly disinfected and 
the party removed from quarantine to detention quarters 
and kept there until two more successive negative reports 
15 



226 APPENDIX 

on separate nose and throat cultures have been made, where- 
upon release may be permitted after proper disinfection. 

710. — All cultures must be taken by a physician or sanitary 
inspector and cultures for release of quarantine shall be tal^en 
with at least twenty-four hours intervening. All cultures 
must be submitted to the laboratory division of the State 
Board of Health or to a laboratory having the official endorse- 
ment of said board. Reports on cultures examined elsewhere 
will not be officially recognized. 

State Health Laws and Regulations, July 16, 1917, p. 43. 

Carriers. — Any person proved to be a carrier of disease 
germs shall be subject to the regulations of the State Board 
of Health relating to the control of persons who may be 
infected with said disease. 

Mississippi. 

Rules and Regulations of the Mississippi State Board of Health 

Governing Infectious Diseases, Bulletin, 

January-March, 1918. 

Diphtheria. — (d) Any child attending school that becomes 
a carrier of diphtheria germs shall be excluded from school 
and quarantined until proper treatment is given for rendering 
the throat free of diphtheria bacilli. Said child shall be 
released from quarantine upon obtaining two negative cul- 
tures from the throat and nose taken forty-eight hours apart, 
provided that during the forty-eight-hour period no spray 
or gargle is used in the throat and nose. 

(e) Any person that becomes a carrier of diphtheria germs 
shall be isolated and the throat shall be properly treated for 
the removal of the diphtheria bacilli. The period of isolation 
for adults or those not attending school shall be left to the 
discretion of the health officer, but the treatment of said car- 
rier must be kept up until two negative cultures are obtained 
from the throat and nose taken twenty-four hours apart, 
provided that during this period no spray or gargle is used 
in the throat and nose by said individuals. 



STATE LAWS AND INFECTION CARRIERS 227 

Missouri. 
No specific regulations regarding infection carriers. 

Nebraska. 
Rules and Regulations, July 12, 1918, p. 31. 

Carriers of Communicable Disease. — It shall be the duty of 
every county or city or village board of health when they 
know or have any good reason to believe that any person, 
although not himself afflicted with a communicable disease, 
is a carrier of such disease, so as to be a menace to the health 
of the public, if allowed to go at large, to cause such person 
to be quarantined in the way and manner set forth under the 
section " Quarantine ; " Provided that the State Health 
Officer may, when in his opinion it is necessary to do so, 
place any such person under quarantine. In all cases of 
quarantine where the party himself is not afflicted with the 
disease, but is a carrier of same, the quarantine shall con- 
tinue until such time as it is determined by the proper tests 
by the State Department of Health that the party is no longer 
a carrier of contagion or a menace to the health of the public, 
or until the officer placing him in quarantine removes the 
quarantine therefrom. 

Any person who being placed under quarantine fails, 
neglects or refuses to comply with the provision of the quar- 
antine, or any person who in defiance of the terms of such 
quarantine shall go into the place where the person so quar- 
antined is being held, shall be deemed guilty of a misde- 
meanor, and, upon conviction, shall be fined not less than 
fifteen dollars ($15) nor more than one hundred dollars 
($100). 

New Hampshire. 
No specific regulations regarding infection carriers, 1912. 



228 APPENDIX 

New York. 

Rules and Regulations. — {Chapter 559, Act of May 17, 1913.) 

Control of Dangerous and Careless Patients. 

Section 326a. — Whenever a complaint shall be made by 
a physician to a health officer that any person .... 
is a carrier of typhoid fever .... and is unable or 
unwilling to conduct himself and to live in such a manner 
as not to expose members of his family or household or 
other persons with whom he may be associated to danger 
of infection, the health officer shall forthwith investi- 
gate the circumstances alleged. If he should find that 
any such person is a menace to others, he should lodge a 
complaint against such a person with a magistrate and on 
such complaint the said person shall be brought before 
such magistrate. The magistrate after due notice and a 
hearing, if satisfied that the complaint of the health officer 
is well founded and that the person is a source of danger to 
others, may commit him to ... a hospital or institu- 
tion, established for the care of persons suffering from any 
such disease or maintaining a room, ward or wards for such 
persons. Such persons shall be deemed to be committed until 
discharged in the manner authorized in this section. . . . 

The chief medical officer of the hospital or other institu- 
tion to which any such person has been committed, upon 
signing and placing among the permanent records of such 
hospital or institution a statement to the effect that such 
person has obeyed the rules and regulations of such hospital 
or institution for a period of not less than sixty days, and 
that in his judgment such person may be discharged without 
danger to the health or life of others, or for any other reason 
stated in full which he may deem adequate and sufficient, 
may discharge the person so committed. He shall report 
each such discharge, together with a full statement of the 
reasons therefor, at once to the health officer of the city, 
village or town from which the patient came and at the next 
meeting of the board of managers or other controlling author- 
ity of such hospital or institution. Every person committed 



STATE LAWS AND INFECTION CARRIERS 229 

under the provisions of this section shall observe all the rules 
and regulations of such hospital or institution. Any patient 
so committed who neglects or refuses to obey the rules or 
regulations of the institution may by direction of the chief 
medical officer of the institution be placed apart from the 
other patients and restrained from leaving the institution. 
Any such patient who wilfully violates the rules and regula- 
tions of the institution or repeatedly conducts himself in a 
disorderly manner may be taken before a magistrate by the 
order of the chief medical officer of the institution. The chief 
medical officer may enter a complaint against such person 
for disorderly conduct, and the magistrate, after a hearing 
and upon due evidence of such disorderly conduct, may 
commit such person for a period not to exceed six months 
to any institution to which persons convicted of disorderly 
conduct or vagrancy or of being tramps may be committed ; 
and such institution shall keep such person separate and 
apart from the other inmates, provided that nothing in this 
section shall be construed to prohibit any person committed 
to any institution under its provisions from appealing to any 
court having jurisdiction for a review of the evidence on which 
commitment was made. 

Communicable Diseases (Reg. Public Health Council, April 

7, 1914). 

Chapter 2. — Regulation 40. — Carriers of Disease Germs.— 
Any person who is a carrier of the disease germs of diphtheria 
or typhoid fever shall be subject to the special rules and 
regulations of the State Department of Health. 

Typhoid Fever. — Care of Carriers (Chapter 371, Act of May 

1, 1916). 

Section 1. — Chapter 49 of the laws of 1909, entitled "An 
act in relation to the public health, constituting Chapter 45 
of the consolidated laws, " is hereby amended by adding a new 
section to be known as section 36a, and to read as follows : 

Section 36a. — Providing for the Care and Maintenance of 
Carriers of Disease. — Whenever an individual is declared by 



230 APPENDIX 

the State commissioner of health as being a carrier of typhoid 
bacilli and whenever, for the protection of the public health, 
the State commissioner of health shall have certified to the 
necessity of continued quarantine, or whenever in accordance 
with the rules and regulations adopted by the State commis- 
sioner of health a carrier of the germs of typhoid fever is 
prevented from carrying on any occupation which would 
enable him to gain a livelihood, such individual may be given 
hospital or institutional care under the surveillance of the 
local health officer at the expense of the State, if such hospital 
or institution in the judgment of the State commissioner of 
health be properly equipped for the care and maintenance 
of said individual. 

When no such hospital or institution is available, and when 
in the opinion of the State commissioner of health such 
individual may be cared for at home or in a private family 
with due regard to the protection of the public health, the 
local charities commissioner or overseer of the poor shall, in 
accordance with the rules and regulations adopted by the 
commissioner of health, furnish necessary medical attendance 
and maintenance. No expenditure for the purposes herein 
authorized shall be contracted for or incurred by any local 
overseer of the poor or charities commissioner until after such 
expenditure has been authorized and approved by the State 
commissioner of health. A verified statement of any such 
approved expense incurred hereunder shall be transmitted 
by the local overseer of the poor or charities commissioner 
to the State commissioner of health. The commissioner 
of health shall examine this statement, and if satisfied that 
such authorized expenses are correct and necessary in accord- 
ance with the rules and regulations adopted by him he shall 
audit and allow the same and when so audited the amount 
thereof shall be paid by the State Treasurer on the warrant 
of the comptroller to such institution or local poor officer. 

Rules and Regulations for Control of Typhoid Carriers. 

Rule 1. — A typhoid carrier is a person who harbors 
typhoid bacilli and emits them, regularly or intermittently. 
This condition may or may not follow a recognized attack 



STATE LAWS AND INFECTION CARRIERS 231 

of typhoid fever. A person continuing to discharge typhoid 
bacilli following an attack of typhoid fever shall be regarded 
as a case, rather than a carrier for a period of at least twelve 
weeks following subsidence of clinical symptoms. After that 
period, the Health Officer may, in his discretion, declare 
such a person to be a carrier. 

Rule 2. — The Health Officer, upon the discovery of a 
typhoid carrier, shall immediately report the fact to the 
State Department of Health, giving the full name, age, 
occupation, and address of such carrier (together with any 
other information relative to possible or probable infection 
of others) and shall also communicate the fact to the carrier 
himself or his guardian, imparting to him detailed information 
regarding the precautions to be observed in disposing of his 
discharges, in preventing contamination of his hands, and 
thus protecting others from infection. Instruction given by 
the Health Officer should include a copy of these rules and 
regulations and directions to wash the hands thoroughly 
with soap and water immediately after using the toilet and 
to use individual towels and drinking and eating utensils, 
which should be thoroughly cleansed, preferably by boiling, 
before being used by others. 

Rule 3. — When an outside toilet is being used regularly 
by a typhoid carrier, it shall be equipped with a watertight 
container so screened as to exclude flies, and the removal of 
the contents for disposal should be in accordance with instruc- 
tions given by the Health Officer. 

Rule 4. — No typhoid carrier may engage in any occu- 
pation involving the handling of milk or other food product 
to be consumed by others. Should a typhoid carrier be dis- 
covered upon a dairy farm, the Health Officer may prohibit 
the sale of milk, cream or butter, except under conditions 
stated in regulation 37, Chapter II, of the Sanitary Code. 

Rule 5. No typhoid carrier shall permanently leave the 
community in which he resides without notification to the 
Health Officer, who is to be informed of his destination, 
including his new address. The Health Officer should im- 
mediately notify the State Department of Health of the 
change of address. 



232 APPENDIX 

Rule 6. The local Health Officer shall visit each typhoid 
carrier within his jurisdiction at least once monthly in order 
to determine whether instructions are being complied with; 
and once in each quarter shall render a report regarding each 
such carrier to the State Department of Health upon a form 
prescribed for the purpose. 

Rule 7. The Health Officer shall cause samples of the 
discharges from each carrier to be examined bacteriologically 
at intervals at a laboratory approved by the State Depart- 
ment of Health, and a carrier may be regarded as recovered 
and be discharged from observation when four successive 
samples, taken not less than seven days apart, shall have been 
found not to contain typhoid bacilli ; except that no negative 
report shall be considered if the specimen has been delayed 
in transit, and in no instance if more than two days have 
elapsed between the collection of the specimen and its 
examination. 

Rules and Regulations for Control of Diphtheria Carriers. 

Rule 1. A diphtheria carrier is a person who harbors in 
the secretions of his nose or throat the bacillus of diphtheria, 
either following recovery from diphtheria or without himself 
having contracted the disease. A person who still harbors 
the bacilli as a result of a recent diphtheria infection shall be 
regarded as a case of the disease, and not as a carrier, until 
at least five weeks have elapsed after the date of the first 
release culture. After that time, the Health Officer may, at 
his discretion, regard such a person as a carrier rather than a 
case. 

Rule 2. The local Health Officer upon the discovery of 
the carrier condition shall immediately advise the carrier 
or his guardians of the condition and give him detailed 
instructions regarding the precautions to be observed in the 
disposal of the secretions of the nose and mouth and in his 
association with other persons. If the carrier is a child 
attending school, the Health Officer shall immediately notify 
the medical school inspector, superintendent, or principal 
of the school, who shall immediately exclude him from the 
school. 



STATE LAWS AND INFECTION CARRIERS 233 

Rule 3. A diphtheria carrier shall not leave the premises 
upon which he resides except under permission from the 
Health Officer, who shall issue such permission only for urgent 
reasons and when he is assured that necessary precautions 
will be taken for the protection of others. But no diphtheria 
carrier may be granted permission to attend church, Sunday 
School, moving picture shows, or other places of public 
assemblage ; and he may be permitted to attend school only, 
when, because of the existence of numerous carriers following 
an outbreak of diphtheria, classes are conducted in separate 
rooms and the children who are carriers are prevented from 
mingling with other children. 

Rule 4. Without permission from the Health Officer 
the premises occupied by a diphtheria carrier shall not be 
visited by children not residing there. When on such 
premises there are children other than the carrier, who are 
attending school or Sunday School, the Health Officer shall 
immediately have cultures taken from their noses and 
throats for examination; and when any such children are 
discovered to be free of diphtheria bacilli, they are to be kept 
apart from the carrier and not permitted to use the same 
eating utensils, toilet articles, etc., used by the carrier. Pend- 
ing the report upon the cultures, all such children shall be 
excluded from school. 

Rule 5. No diphtheria carrier shall engage in any occu- 
pation involving the handling of milk or other food to be 
consumed by others, except that, if a housewife, she may with 
the permission of the Health Officer continue to prepare 
food for the family or household, provided each member of 
the same has been shown, by means of the Schick test, to 
be immune to diphtheria. Should the carrier reside or be 
employed upon a farm producing milk for sale, the Health 
Officer may prohibit the sale of the milk, cream, butter, or 
cheese from such farm, except as provided in Reg. 37, 
Chapter II, of the Sanitary Code. 

Rule 6. When a virulence test upon a culture from a 
diphtheria carrier has shown the organisms not to be virulent 
for guinea-pigs, the imposed restrictions may be removed by 
the Health Officer. 



234 APPENDIX 

Rule 7. A diphtheria carrier may be regarded as free 
of the bacilli and be discharged from observation and restraint 
when two negative cultures, taken at intervals of no less than 
twenty-four hours, have been obtained. 

Rule 8. Should a diphtheria carrier be unable or unwill- 
ing to observe the precautions herein indicated, the Health 
Officer may take such further action as may be necessary to 
safeguard public health, pursuant to Sections 25 and 326a 
of the Public Health Law. 

North Carolina. 
No specific regulations regarding infection carriers, 1917. 

Oregon. 

Rules and regulations concerning the reporting and control 
of communicable diseases, 1918. 

Section 11. — To prevent the possibilities of diphtheria 
carriers entering schools, cultures should be made from nose 
and throat of pupils before being admitted to school. 

Section 20. — A constant lookout should be maintained 
for suspected typhoid carriers, and when found reported to 
the State Board of Health. 

Pennsylvania. 

There are no specific regulations relating to the manage- 
ment of infection carriers. Each case is dealt with indi- 
vidually and controlled by virtue of the general powers 
granted by law to the Commissioner of Health.* 

Rhode Island. 
No specific regulations regarding infection carriers. 

South Dakota. 
No specific regulations regarding infection carriers, 1915. 

* As per letter from the Acting Commissioner of the Department of 
Health. 



STATE LAWS AND INFECTION CARRIERS 235 

Tennessee. 
No specific regulations regarding infection carriers. 

Texas. 

Xo specific regulations regarding infection carriers, 1917. 

Vermont. 

(Reg. Board of Health, May 6, 1915.) 

Rule 18. — Carriers of Disease Germs. — Any person who 
is a carrier of the disease germ of Asiatic cholera, diphtheria, 
epidemic dysentery, epidemic cerebrospinal meningitis, 
poliomyelitis (infantile paralysis), scarlet fever or typhoid 
fever shall be subject to such rules as the ^tate Board of 
Health shall make for the control of such persons. 

Virginia. 
Xo specific regulations regarding infection carriers, 1916. 

Washington. 
Xo specific regulations regarding infection carriers. 

West Virginia. 
Xo specific regulations regarding infection carriers, 1916. 

Wisconsin. 

Rides of the State Board of Health Pertaining to the Prevention 
and Control of Communicable Diseases, 1917.* 

Typhoid Fever. — In every case of typhoid the patient should 
be instructed of the danger he may be to the public and given 
instructions as to how to protect others against the infection 
which he is carrying. It is impossible to know whether a 
person is a carrier without a bacteriological examination of 

* There are evidently no specific regulations, the above being notices to 
physicians. 



236 APPENDIX 

his excreta, urine and feces. Therefore, in every case of con- 
valescing typhoid, specimens of urine and feces should be 
collected in clean sterile bottles and sent to the laboratory 
together with a letter giving a full history of the patient. 
These patients should not be released from observation until 
two successive negative reports have been obtained. 

Diphtheria. — A certain number of those who have diph- 
theria become carriers for a longer or shorter time. Some- 
times the organisms persist in the throat for months after 
the patient is well. It is necessary, however, to keep these 
people isolated in order to prevent the spread of the disease. 

There are a few who never had the disease but harbor the 
organism in their throats, which, when it finds its way into 
another's throat, will produce diphtheria. These carriers 
should be located so that the further spread of the disease 
may be prevented. The throat of every child entering school 
should be swabbed and the swab sent to the laboratory for 
diagnosis. Many school epidemics may be prevented by 
this means. 



MUNICIPAL ORDINANCES, RULES AND REGULATIONS 
PERTAINING TO INFECTION CARRIERS. 

Atlantic City, N. J. 
No specific regulations. 

Baltimore, Md. 
No specific regulations. 

Brockton, Mass. 
No specific regulations. 

Chicago, III. 

Quarantine of Diphtheria Carriers. — Persons known to be 
diphtheria carriers must be placed in quarantine and isolated 
as far as possible. Children of the family who yield negative 



ORDINANCES, RULES AND REGULATIONS 237 

cultures and who do not come in contact with the carrier in 
any way need not be excluded from the school. Quarantine 
of diphtheria carriers should be raised when two negative 
cultures from nose and throat of carrier are obtained on 
consecutive days. 

Columbia, S. C. 
(Reg. Board of Health, October 19, 1915.) 

1. That cultures shall be made from the secretions of the 
nose and throat of all other members of the family who have 
been in contact with the one suffering with diphtheria, in the 
event effective isolation of the patient is carried out, and that 
no one be allowed to go and come from the quarantined house 
unless said culture from the secretion of the nose and throat 
is negative for diphtheria bacilli. 

2. That upon the termination of the case the school 
children of the family shall not be allowed to return to school 
until one culture from the secretion of the nose and throat 
is negative for diphtheria bacilli. 

3. The health officer is enjoined to see that this regula- 
tion is carried out. 

Detroit, Mich. 

Code of Regulations. — Section D. — Persons who have 
recently come in contact with persons suffering from cerebro- 
spinal meningitis, cholera, diphtheria, dysentery, erysipelas, 
paratyphoid fever, plague, lobar pneumonia, poliomyelitis, 
septic sore-throat, typhoid fever (and other communicable 
diseases) shall be subject to the rules of quarantine, isolation, 
etc., as are hereinafter provided for each specific disease. 

Galveston, Tex. 
No specific regulations. 

Macon, Ga. 
No specific regulations. 



238 APPENDIX 

Minneapolis, Minn. 

The law under which the health department was organized 
gives the health officer the right to take reasonable precau- 
tions to protect the public. In the course of time customary 
proceedings have been established without the formality of 
legalizing them. 

In typhoid fever members of the household are not allowed 
to work in foodstuffs until they are immunized ( ! ? ) . Food- 
workers having had typhoid fever are not allowed to go back 
to work until a proper stool test has been made.* 

New Orleans, La. 
No specific regulations. 

Newport News, Va. 
(Reg. Board of Health, March 5, 1915.) 

18. The minimum period of quarantine for cases of diph- 
theria shall be fourteen days, except where two successive 
negative cultures are made on two successive days, and then 
the minimum period shall be seven days, provided that anti- 
toxin has been used (! ?). 

Newton, Mass. 

No specific regulations. 

"In cases where a person is found to be a carrier through a 
laboratory examination he is treated as a person ill with the 
disease in question and becomes amenable to the regular 
rules governing such disease." f 

New York City. 
(Reg. Department of Health, March 30, 1915.) 

Infection Carriers. — Section 86. 

Reg. 3. — Any person who is a carrier of the disease germs 
of Asiatic cholera, bacillary dysentery, epidemic cerebro- 

* As per letter from the Health Commissioner. 

t As per letter from the Chairman of the Board of Health. 



ORDINANCES, RULES AND REGULATIONS 239 

spinal meningitis, poliomyelitis or typhoid fever shall be 
subject to the regulations governing clinical cases of these 
respective diseases. 

Examination of Specimens of Feces and Urine of Convalescent 

Patients. 

(Reg. Department of Health, December 21, 1915.) 

Reg. 5. — In every case of typhoid fever the attending 
physician shall submit to the department of health specimens 
of feces and urine for examination for the presence of typhoid 
bacilli. Such specimens shall be submitted at least ten days 
after the patient's temperature reaches normal and before 
he or she shall resume his or her occupation. If in any case 
typhoid bacilli are found to be present in the excreta, such 
convalescent patient shall not resume his or her occupation 
without the permission of the department of health. 

Philadelphia, Pa. 
No specific regulations. 

Portland, Me. 
(Reg. Board of Health, September 3, 1915.) 

Section 1. — All persons quarantined for diphtheria and 
all contacts or exposed individuals of school age shall be 
removed from quarantine only after the obtaining of two 
successive negative throat cultures. The first culture shall 
be taken not earlier than the fourteenth day from the 
beginning of the quarantine and the second culture not earlier 
than twenty-four hours after. 

Section 2 — In the case of a child of school age removed 
from an infected household at the beginning of quarantine, 
two throat cultures at least tw T enty-four hours apart shall be 
obtained as soon as possible, and if the cultures are negative 
such child may return to school at the end of one week's 
time after removal from infected household. 

Section 3. — These rules have no bearing on the question 
of immunization, which should be performed as usual. 



240 APPENDIX 

Salem, Mass. 
No specific regulations. 

St. Louis, Mo. 
No specific regulations. 

MARITIME QUARANTINE AT NEW YORK. 

Vessels Liable to Quarantine (Reg. Department of Health, 
December 21, 1915.) 

Resolved, That section 352 of the Sanitary Code of the 
Board of Health of the Department of Health of the City 
of New York be and the same is hereby amended and made 
to read as follows: 

Section 352. — Vessels from Infected Ports, or Liable to 
Quarantine; Not to Be Brought Within 300 Yards of Docks or 
Piers Unless Permitted. — No master, charterer, consignee, 
or other person shall order, bring, or allow (having power 
and authority to prevent) any vessel or person, or article 
therefrom, from any infected port, or any vessel, or person or 
article therefrom, liable to quarantine, according to the ninth 
section of the three hundred and fifty-eighth chapter of the 
laws of 1863 (or under any other laws, and whether such 
quarantine has been made or suffered or not), to come or be 
brought to any point nearer than 300 yards from any dock, 
pier, or building, in the city of New York without a permit 
therefor issued by the board of health, or otherwise than in 
accordance with the terms of said permit and with the regu- 
lations of said board. Nor shall any vessel, or person or thing 
therein or therefrom, having been in quarantine, come or be 
brought or be permitted to remain within the last-named 
distance of any last-named place, without a permit therefor 
issued by the board of health or otherwise than in accordance 
with the terms of said permit and with the regulations of said 
board. 



QUARANTINE LAWS OF THE UNITED STATES 241 

QUARANTINE LAWS OF THE UNITED STATES. 

An Act to Prevent the Introduction of Contagious Diseases from 
One State to Another or for the Punishment of 
Certain Offenses. 

(U. S. Statutes at Large, Vol. xxvi, Chapter 51, p. 31. 
Approved March 27, 1890.) 

Be it Enacted by the Senate and House of Representatives of 
the United States of America in Congress Assembled, That 
whenever it shall be made to appear to the satisfaction of 
the President that cholera, yellow fever, smallpox, or plague 
exists in any State or Territory, or in the District of Columbia, 
and that there is danger of the spread of such disease into 
other States, Territories, or the District of Columbia, he is 
hereby authorized to cause the Secretary of the Treasury to 
promulgate such rules and regulations as in his judgment 
may be necessary to prevent the spread of such disease from 
one State or Territory into another, or from any State or 
Territory into the District of Columbia, or from the District 
of Columbia into any State or Territory, and to employ such 
inspectors and other persons as may be necessary to execute 
such regulations to prevent the spread of such disease. The 
said rules and regulations shall be prepared by the Super- 
vising Surgeon-General of the Marine Hospital Service under 
the direction of the Secretary of the Treasury. And any 
person who shall willfully violate any rule or regulation so 
made and promulgated shall be deemed guilty of a mis- 
demeanor, and upon conviction shall be punished by a fine 
of not more than five hundred dollars, or imprisonment for 
not more than two years, or both, in the discretion of the 
court. 

An Act Granting Additional Quarantine Powers and Impos- 
ing Additional Duties upon the Marine Hospital Service. 

(U. S. Statutes at Large, Vol. xxvii, Chapter 114, p. 449, 
Approved February 15, 1893.) 

Section 3. — That the Supervising Surgeon-General of 

the Marine Hospital Service shall, immediately after this 
16 



242 APPENDIX 

act takes effect, examine the quarantine regulations of all 
State and municipal boards of health, and shall, under the 
direction of the Secretary of the Treasury, cooperate with and 
aid State and municipal boards of health in the execution 
and enforcement of the rules and regulations of such boards 
and in the execution and enforcement of the rules and regula- 
tions made by the Secretary of the Treasury to prevent the 
introduction of contagious or infectious diseases into the 
United States from foreign countries, and into one State or 
Territory or the District of Columbia from another State 
or Territory or the District of Columbia; and all rules and 
regulations made by the Secretary of the Treasury shall 
operate uniformly and in no manner discriminate against 
any port or place; and at such ports and places within the 
United States as have no quarantine regulations under State 
or municipal authority, where such regulations are, in the 
opinion of the Secretary of the Treasury, necessary to pre- 
vent the introduction of contagious or infectious diseases 
into the United States from foreign countries, or into one 
State or Territory or the District of Columbia from another 
State or Territory or the District of Columbia, and at such 
ports and places within the United States where quarantine 
regulations exist under the authority of the State or munici- 
pality which, in the opinion of the Secretary of the Treasury, 
are not sufficient to prevent the introduction of such dis- 
eases into the United States, or into one State or Territory 
or the District of Columbia from another State or Territory 
or the District of Columbia, the Secretary of the Treasury 
shall, if in his judgment it is necessary and proper, make 
such additional rules and regulations as are necessary to 
prevent the introduction of such diseases into the United 
States from foreign countries, or into one State or Territory 
or the District of Columbia from another State or Territory 
or the District of Columbia, and when such rules and regu- 
lations have been made they shall be promulgated by the 
Secretary of the Treasury, and enforced by the sanitary 
authorities of the States and municipalities, where the 
State and municipal health authorities will undertake to 
execute and enforce them; but if the State or municipal 



QUARANTINE LAWS OF THE UNITED STATES 243 

authorities shall fail or refuse to enforce said rules and regu- 
lations the President shall execute and enforce the same and 
adopt such measures as in his judgment .shall be necessary 
to prevent the introduction or spread of such diseases, and 
may detail or appoint officers for that purpose. The Secre- 
tary of the Treasury shall make such rules and regulations 
as are necessary to be observed by vessels at the port of 
departure and on the voyage, where such vessels sail from any 
foreign port or place to any port or place in the United States, 
to secure the best sanitary condition of such vessel, her 
cargo, passengers and crew, which shall be published and 
communicated to and enforced by the consular officers of the 
United States. None of the penalties herein imposed shall 
attach to any vessel or owner or officer thereof until a copy 
of this act, with the rules and regulations made in pursuance 
thereof, has been posted up in the office of the consul or other 
consular officer of the United States for ten days in the port 
from which said vessel sailed; and the certificate of such 
consul or consular officer over his official signature shall be 
competent evidence of such posting in any court of the 
United States. 

Section 5. — That the Secretary of the Treasury shall 
from time to time issue to the consular officers of the United 
States and to the medical officers serving at any foreign port, 
and otherwise make publicly known, the rules and regula- 
tions made by him, to be used and complied with by vessels 
in foreign ports, for securing the best sanitary conditions of 
such vessels, their cargoes, passengers and crew, before their 
departure for any port in the United States and in the course 
of the voyage, and all such other rules and regulations as 
shall be observed in the inspection of the same on the arrival 
thereof at any quarantine station at the port of destination, 
and for the disinfection and isolation of the same, and the 
treatment of cargo and persons on board, so as to prevent 
the introduction of cholera, yellow fever, or other contagious 
or infectious diseases ; and it shall not be lawful for any vessel 
to enter said port to discharge its cargo or land its passengers 
except upon a certificate of the health officer at such quaran- 
tine station certifying that said rules and regulations have 



244 APPENDIX 

in all respects been observed and complied with, as well on 
his part as on the part of the said vessel and its master, in 
respect to the same and to its cargo, passengers and crew; 
and the master of every such vessel shall produce and deliver 
to the collector of customs at said port of entry, together 
with the other papers of the vessel, the said bills of health 
required to be obtained at the port of departure and the 
certificate herein required to be obtained from the health 
officer at the port of entry, and that the bills of health herein 
prescribed shall be considered as part of the ship's papers, and 
when duly certified to by the proper consular or other officer 
of the United States, over his official signature and seal, shall 
be accepted as evidence of the statements therein contained 
in any court of the United States. 

Section 7. That whenever it shall be shown to the satis- 
faction of the President that by reason of the existence of 
cholera or other infectious or contagious diseases in a foreign 
country there is serious danger of the introduction of the 
same into the United States, and that notwithstanding the 
quarantine defense this danger is so increased by the intro- 
duction of persons or property from such country that a 
suspension of the right to introduce the same is demanded 
in the interest of the public health, the President shall have 
power to prohibit, in whole or in part, the introduction of 
persons and property from such countries or places as he 
shall designate and for such period of time as he may deem 
necessary. 

Section 8. That whenever the proper authorities of a 
State shall surrender to the United States the use of the build- 
ings and disinfecting apparatus at a State quarantine station 
the Secretary of the Treasury shall be authorized to receive 
them and to pay a reasonable compensation to the State for 
their use, if, in his opinion, they are necessary to the United 
States. 

INTERSTATE QUARANTINE REGULATIONS. 

Section 27. — Common carriers shall not receive upon any 
car, vessel, vehicle, or conveyance operating in interstate 



INTERSTATE QUARANTINE REGULATIONS 245 

traffic any person affected with diphtheria, measles, or 
whooping-cough, or any person known to be a carrier of the 
bacillus diphtheria?, unless removal and entrance permits 
have been granted by the State or local health officers at the 
places of departure and arrival, and unless said person is 
placed in a separate compartment and is accompanied by a 
properly qualified nurse or attendant and unless such nurse 
or attendant has pledged himself or herself in writing, to the 
common carrier, to comply with the following regulations 
while in transit: 

(a) 1 . Communication with the compartment within which 
the patient is traveling shall be restricted to the minimum 
consistent with the proper care and safety of the patient. 

2. All dishes or utensils used by the patient en route 
shall be placed in a 5 per cent, solution of carbolic acid or 
disinfecting fluid of equivalent disinfecting value for at least 
one hour before being allowed to leave the compartment. 

3. All sputum and nasal discharges from the patient 
shall be received in gauze or paper, which shall be deposited 
into a closed container and which shall be destroyed by 
burning or received in a 5 per cent, solution of carbolic acid 
or disinfecting fluid of equivalent disinfecting value placed 
in a covered vessel and allowed to stand undisturbed for at 
least two hours after the last addition thereto. 

(b) Immediately upon the disembarkation of the patient 
the common carrier shall close the compartment the patient 
has vacated, without the removal of any of its contents, and 
shall keep the same closed until disinfection. 



INDEX. 



Agglutination reaction in cholera 
carriers, 35 
in typhoid carriers, 90 
test in diagnosis of dysentery 
carriers, 138 
of meningococcus car- 
riers, 127 
of pneumococcus car- 
riers, 172 
of typhoid carriers, 

90 
macroscopic slide 
method, 93 
Andrade's indicator, 96 
Avery's artificial mouse, 174 

method of determining 
the type of pneumo- 
cocci, 171 



B 



Bacillary dysentery, carriers of. 

See Dysentery. 
Bazillentrager, 19 
Bile test for pneumococci and 

streptococci, 197 
Blake's method of determining the 

type of pneumococci, 172 
Bronchopneumonia, dissemination 

of, by carriers, 187 



Camp septicemia, dissemination of, 

by carriers, 187 
Carriers, active, 19 

definition of term, 17 

passive, 20 



Chloramin-T in treatment of car- 
riers, 128 
preparation of, 129 
Cholera, active carriers, 23 

dissemination by carriers, 21, 

25 
duration of carrier stage, "23, 

24 
fecal carriers, 30 
habitat of organism in carriers, 

30 
intermittent elimination in 

carriers, 30 
management of carriers, 36 
mode of infection by, 29 
passive carriers, 24 
recognition of carriers, 32 
release of carriers, 34 
urinary carriers, 30 
vibrio, culture of, 33 
in bile, 30 
in feces, 30 
in urine, 30 

serological tests for, 34 
virulence of organisms in 
carriers, 25 



D 



Dauerausscheider, 19 
Diphtheria, active carriers, 38 
bacillus, culture of, 49 
staining of, 49 
virulence test, 51 
. dissemination of, by carriers, 
46 
habitat of organism in carriers, 

43 
management of carriers, 52 
medical treatment of carriers, 
53 



248 



INDEX 



Diphtheria, mode of infection by 
carriers, 45 
passive carriers, 40 
recognition of carriers, 49 
surgical treatment of carriers, 

56 
vaccine treatment of carriers, 

54 
virulence of organisms in 
carriers, 44 
Drigalski-Conradi medium, 91 
Dunham's solution, 33 
Dysentery, bacillary, active car- 
riers, 134 
cultivation of organism, 

137 
cultural characteristics of 

organism, 138 
dissemination of, by car- 
riers, 134 
management of, 139 
manner of infection by, 

137 
passive carriers, 136 
recognition of, 137 
serological characteristics 

of organism, 138 
types of organism, 138 



E 



El Tor carriers, 34 
Endo medium, 95 
Erysipelas, dissemination of, by 
carriers, 194 



Face masks, utility of, in prevent- 
ing infection, 53, 132, 176, 199 



G 



Gall-bladder, infection of, in 
cholera carriers, 30 
in typhoid carriers, 73 
Gall-stones in typhoid carriers, 75 
Glucose-blood broth, 1 70 
Grippe, dissemination of, by car- 
riers, 186, 192 
relation to camp septicemia 
and bronchopneumonia, 192 



H 



Hemolytic test for streptococci, 

197 
Hiss's serum water media, 124, 198 



I 



Infantile paralysis. See Poliomye- 
litis. 
Influenza (Pfeiffer's type), dis- 
semination of, by 
carriers, 204 
duration of carrier 

stage, 206 
habitat of organisms 

in carriers, 206 
management of car- 
riers, 207 
mode of infection by 

carriers, 207 
recognition of car- 
riers, 207 
Influenza bacillus, cultivation of, 
207 
cultural characteristics of, 

207 
morphological character- 
istics of, 208 
Interstate quarantine regulations, 
244 



K 



Krumwiede's brilliant green me- 
dium, 96 
method of determining the type 
of pneumococci in sputa, 174 



Loeffler's blood serum, 49 
solution, 53 



M 



Maritime quarantine at New 

York, 240 
Masks. (See Face Masks.) 
Meningitis, meningococcus, active 

carriers, 107 



INDEX 



249 



Meningitis, meningococcus, dis- 
semination of, by car- 
riers, 106, 115, 117 
duration of carrier state, 

108, 110 
habitat of organisms in 

carriers, 112 
management of. carriers, 

128 
medical treatment, 128 
passive carriers, 109 
quarantine of carriers, 130 
recognition of carriers, 

122 
release of carriers, 132 
virulence of organisms in 
carriers, 111 
Meningococcus, cultivation of, 122 
cultural characteristics of, 127 
serological characteristics of, 
127 
Municipal ordinances, rules and 
regulations pertaining to infec- 
tion carriers, 236 



N 

Neisser's stain, 50 
Nutrose, substitute for, 92 



O 

Olitsky's method, 123 



Paratyphoid bacilli, cultural char- 
acteristics of, 94 
demonstration of, in feces, 

91 
serological behavior of, 93 
Paratyphoid carriers, 103 
Plague bacillus, culture of, 64 

morphology of, 65 
Plague carriers, 61 
active carriers, 61 
management of, 65 
" mode of infection, 63 
passive carriers, 62 
recognition of, 64 



Pneumococcus, different types of, 
154 
in normal mouths, 157 
isolation of organism, 169 
relation to pneumonia, 

154, 157 
serological characteristics, 
154, 171, 172, 174, 175 
type determination in 
saliva, 169 
in sputa, 173, 174 
by aggluti- 
nation 
. test, 172 
by precipi- 
tin test, 
171, 175 
Pneumonia (pneumococcus type), 
active carriers, 156 
disinfection of carriers, 

178 
dissemination of, by car- 
riers, 156, 157, 163 
duration of carrier state, 

160 
habitat of organism in 

carriers, 160 
management of carriers, 

176, 179 
mode of infection by car- 
riers, 162 
passive carriers, 156 
prophylactic vaccination 

against, 180 
recognition of carriers, 

169 
relation of common colds 
to, 160 



Q 



Quarantine laws of the United 
States, 241 



Russell's double sugar medium, 



Septic sore-throat, dissemination 
of, by carriers, 193 



250 



INDEX 



Serum agar, 123 

State laws and regulations pertain- 
ing to infection carriers, 212 
Streptococci, classification of, 195 
cultivation of, 196 
cultural characteristics, 197 
serological characteristics, 196 
Streptococcus carriers, 188 

duration of carrier state, 

191 
habitat of organisms in 

carriers, 191 
management of carriers, 

198 
manner of infection by 

carriers, 191 
mode of invasion, 192 
recognition of carriers, 195 
hemolyticus, 196 

as cause of bronchopneu- 
monia, 187 
of camp septicemia, 
187 
mucosus capsulatus, 196, 198 
viridans, 196 
Streptococcus infections : 
bronchopneumonia, 187 
camp septicemia, 187 
dissemination by carriers, 185 
duration of carrier state, 191 
ervsipelas, 194 
grippe, 186, 192 
habitat of organisms in car- 
riers, 191 
management of carriers, 198 
manner of infection by carriers, 

191 
mode of invasion, 192 
prophylactic vaccination 

against, 201 
puerperal fever, 194 
recognition of carriers, 195 
septic sore-throat, 193 



Typhoid bacillus, culture of, 91 
in bile, 73 
differentiation of, from 

other organisms, 94 
in feces, 68, 70 
in urine, 70 



Typhoid active carriers, 68 

bacillus, serological character- 
istics of, 93 

carriers, 67 

dissemination of disease by, 
67, 79, 82 

fecal carriers, 68, 70 

fever, dissemination of, by car- 
riers, 67, 79, 82 m 
prophylactic vaccination 
against, 103 

gall-bladder infection in, 73 

gall-stones in, 75 

habitat of organisms in, 72 

intermittent elimination of 
organisms by, 71 

management of, 99 

manner of infection by, 81 

Mary, history of, 82 

medical treatment of, 99 

passive carriers, 70 

pus carriers, 89 

quarantine of, 100 

recognition of, 90 

surgical treatment of, 100 

tendency of women to become 
carriers, 72 

urinary carriers, 70 

virulence of organisms in, 77 

Widal reaction in, 90 



U 



Urinary carriers of the cholera 
bacillus, 30 
of the typhoid bacillus, 70 



Vaccination against pneumo- 
coccus pneumonia, 181 
typhoid, 103 
Vaccine treatment of diphtheria 
carriers, 54 



W 



West swab tube, 125 
Widal reaction in typhoid carriers, 
90 






